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APPLICATION FOR PERMIT SAN JOAQM LOCAL HEALTH DISTRICT .p r '4 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 4 ^!� � 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 Regulations of the San Joaquin tical Health District. Job Address.3 101 �!yfj'A! Q * Subdivision Name a��+ Owner's Name �� 1 �' Address t4/ 6 ��` Phone 47 �2!04 Contractor's Name -T,I-E License No. Phone _ 1 TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION W PUMP INSTALLATION SYSTEM REPAIR OTHER 1 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 U Open Bottom [I Manteca Oia, of Well Excavation U Domestic/Private 7 Gravel Pack ❑ Tracy Dia. of Well Casing Public 11 Other ❑ Delta Type of Casing Irrigation Approx. Eastern Specifications ❑ Cathodic Protection Depth roDepth of Grout Seal LJ 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`) O Depth Filler Material (Below 50') f M I TYPE OF SEPTIC WORK: NEW INSTALLATION' ` REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is !!�-`` available within 200 feet.) I Installation will serve: Residence _ Commercial — Other Number of living units: iZ Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS Cl 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 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 shall employ persons subject to workman's compensation laws of California." The applicn ust cal for all required inspections. Complete drawing on reverse side. Signed Title: Date: OR DEP RTMENT USE ONLY ❑ Application Accepted by Area _ Stk 466-6791 Ufy`� f1 Additional Comments: �] Lodi 369-3621 (�ha t W"y 3 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date � ❑ Tracy 835-6385 ��, i�jAnplicant - Return all copieseErvironmental Health Permit/Services 1601 E. Hazelton AGe., P.O. Box 2009, Stk., CA 95201 1v ,{ [FEE, BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEEPERMITINFNO. 00 �- S..GJ�'i l �p EH 13-24 REV, 10/82 lo/s2 500 �,fv 14-26