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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 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 com fiance with San Joaquin County Ordinance No.' 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of th �7aquin Local Health District. Job AddresWZ 9497 .P4 9"R R D Subdivision Name Owner's Name Address IC A Phone Contractor's Name r�� (/��vp License No. 7 �_ Phone ! TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j { 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 ❑ IndustrialBottom en 0 ❑ P ❑Manteca Dia, of Well Excavation ❑ Domestic/Private -' Gravel-Pack, Trac \� —❑ ❑ y Dia. of Well Casing ❑ PublicIt Irri ation ❑Other ❑:Delta Type of Casing F-1 9 Approx. ❑ Eastern F Specifications 1 ❑Cathodic Protection Depth': �- ❑Geophysical F . Depth.of Grout Seal F-1Other Type of Grout 1 , ; Surface Seal Installed by ) \} Repair Work Done r] ;Type of"Pump f ;' H.PState Work Done Well Destruction ❑ iWell Diameter ' Sealing Material (top 501) Depth Fill,er Material (Below 50') + \ TYPE OF SEPTIC'WORK:iNEW.INSTALLATION• REPAIR/ADDITIONseepage-pit. p public sewer is LI (No septic tank or ermi�tted�if - available within 200 feet.) Installationwillserve: Residnce Commercial Other: Number of living uniFts; 1Number of bedrooms -� Lot size 't Character of soil to a depth.of'3 feet: Water table depth SEPTIC TANK ) Type/Mfg . ,[„ CapacityNo. Compartments PKG-, TREATMENTS PLT. ❑k. Type/Mf§J t� � Capacity-, Method of Disposal ' { SEWAGE SYSTEM Distance to nearest: Well ��:Foundation P V Property Line F� i DESTRUCTION ❑ �� "►^d F .• ice_ P y rt LEACHING LINE ,,I,❑\'No. &'Cength Of Lines � ,� 4 Total length/size _ ,d- FILTER BED Distance,-to nearest:. .Wel,l ftF9`Foundation Property Line SEEPAGE PITS9 " peth' C' ❑ p �'` `Size Number � SUMPS ❑ Distance to nearest: Well'-:� Foundion„ Property Line DISPOSAL PONDS' "� Y I hereby certify that I have prepared'Rthis 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`Lgcal 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 sha]l employ persons subject to workmarr,s'compensation laws of California." The applicant must call f a quire nspections. Complete 'draw ing on reverse side. M Signed X i Title: E� t t Date: 1 F KNT USE ONLY i Application Accepted -by Area E] Stk 466-6781 Additional Comments: t ❑ Lodi 369-3621 Pit or Grout Inspection by i Date Ll Manteca 823-7104 Final Inspection by I.bate. a Tracy 835-6385 Applicant - Return all copies to,-'En ironmenta H alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA1 95201 IN FEE BASE AMOUNT DUE i� AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 -..kms.:' ._ ._ ., _._.._. _._...-10/82 500. 14-26 f