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APPLICATION FOR PERM; SAN JOAQLiN LOCAL }HEALTH DISTRICT 2 �j 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �✓ v 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 the 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 Re ulations of he San Joaquinocal Health District. ��44 Job Address Subdivision Name w d Owner's Name Ir AddressW�lv l Phone Contractor's Name License No. �(�fi7Z/ Phone 36F TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER ALL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casirg Public I—] ❑ ❑Other Delta Type of Casing cp V Irrigation Approx. ❑ Eastern � Cathodic Protection Depth specifications d " Depth of Grout Seal [�Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION � REPRIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence' •`� Commercial _ Other Number of living units: I_____,,_"_ Number of bedrooms Lot size DgfeA, Character of soil to a depth of feet: Water table depth r SEPTIC TANK Type/M - Capacity/�_. .-,__ No. Compartments Z PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well K110r Foundation I_ Property Line !c]V r DESTRUCTION LEACHING LINE �'�} No. & Length of lines c7 Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation -2,0 r Property Line ' SEEPAGE PITS +� Depth LT'LT' Size ir a Number Z SUMPS ❑ Distance to nearest: Well /1(2 FoundatiorProperty 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 workman§ 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 issued, I sh emV oy persons subject to workman's compensation laws of California." The applic st 1 fo quired inspections. Complete drawing on reverse side, Signed K Title: (9(.0 o ! Date: ' FOR DEPARTMENT USE ONLY Application Accepted by Area [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection bA Date Manteca 823-7104 Final Inspection by _ �t,t Date ❑ Tracy. 835-6385 Applicant - Return all co pi to: Enilirpnmgntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 =� BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. eQ (p g349,3 EH 13-24 REV. 10/82' ti's 10/82 500 14-26 '