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APPLICATION FOr2.PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT �Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 3 r Telephone (209) 466"-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or' install th'e work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation of he San Joaquin Lo a1 Health District. Job Address Subdivision Name Owner's Name (: rV> Address "41164tf1 hone Contractor's Name License No. Phoned I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing '" ❑ Public [—I Other ❑ Delta V Irrigation Approx. E] Eastern Type of Casing ❑ Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal Other Type of Grout ; Surface Seal Installed by Repair Work Done Type of Pump H.P. *. * State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) i Depth Filler Material (Below 50') 4 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION (No septic tank or seepage pit permitted if public sewer is # available within 200 feet.) D Installation will serve: Residence _ Commercial ther ' Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: + Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �k PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION '❑ I aj LEACHING LINE No. & Length of lines R 07C 7L Total length/size )( e FILTER BED F7 Distance to nearest: Well Foundation"�jS 1 -- Property Line�Mt5 IL;4-1 SEEPAGE PITS ❑ Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with-San Joaquin county ordinances, state laws, and"rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is ' ued, I shall emplo persons subject to workman's compensation laws of California." The ap6r", t t call r 11 r it inspections. Complete drawl g an re erse side. ''T Signed -ri>9L� Title: � Q`' Oate:� I DEPARTMENT SE ONLY i Application Accepted-by Area --02— I�Ctk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b DateLJ Manteca 823-7104 Final Inspection by Date 2 KSJ L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95202 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO qS to 117 ~-SS EH 13-24 REV. 10/82 10/82 500 14-.26 S