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APPLICATION FOR PERMIT SAN JOAQU'iN LOCAL H;ALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 465-6781 DATE ISSUEDate-- PERMIT EXPIRES I 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 S and the Rules and Regul tions of. the San Joaquin Local Health District. Job Address a D Subdivision Name �L Owner's Name �Mlr/� _ Address C2_2r �/f��S�'jJg�JJ Phone Contractor's Name /z, ri( . License No. :_ Phone �r a S-V TYPE OF WELL/PUMP WORK: NEN WELL WELL REPLACEMENT ❑ DESTRUCTION h W PUMP INSTALLATION SYSTEM REPAIR OTHER I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Dia, of Well Excavation LJ Oomestic/Private Gravel Pack Tracy Dia. of Well Casing Public [ Other Delta Type of Casing V Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical - --- a ,Type of Grout ' U Other Surface Seal Installed by , Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) _ W Depth Filler Material (Below 50') TYPE OF, SEPTIC WORK: NEW','INST'ALLATION U REPAIR/ADDITION .J .(No septic tank or seepage pit permitted if public sewer is �fl av`afla61e'within 200 feet )-- " Installation will serve: Residence _v Commercial Other Number of living units: Number of bedrooms Lot size -- Character of soil to a depth of 3 feet: Water table depth SEPTICTANK Vj Type/Mfg Y CapacityNa. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal I SEWAGE SYSTEM Distance to nearest: Well Foundation ,Property Line DESTRUCTION i F. LEACHING LINE Na. & Length of lines ._ Total length/size FILTER BED Distance to-nearest: Well{ /-v Foundation Property Line � ) 5 SEEPAGE PITS .Depth ` Size Number SUMPS Distance to nearest' Well Foundation Property Line DISPOSAL PONDS ' �. �• A 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 regula•tions-of-the.San Joaquin -Local Health District. eome_owner or licensed'agent's,signature.cerfifies`'the'following: "I certify that in the performance of the work for which this permit is issued, I shall not employ aryfperson in such manner as to become subject to workmanb 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 shall employ persons subject to workman's compensation laws of California." The applicant must call 2 reguir d inspections.' Complete drawing on reverse side. I Signed X r _ Title: Date: �'��"°�� FOR.DEPARTMENf'USE ONLY ((( Application Accepted by Area Stk 466-6781 Additional Comments: ' Lodi 369-3621 Pit or Grout Inspection by i Date Manteca 823-7104 [Final Inspection by 4 Date -" L Tracy 835-6385 Applicant 7. Return all' copies to: Environ al Health Permit/Services 1601 E. Hazel on Ave., p.O, Box 2009, Stk., CA 95201 t FFEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT N0. to `il B3- } EH 13-24 REV.^10/82 10782-5 14-2fi