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TIP, 1 ? � APPLICATION FOR PERMIT 1 q{�p'] SPN JOAQUiN LOCAL HEA-.LTH DISTRICT / 11JJ?93 r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, Telephone (209) 466-6781 sr"I 1C,^QUN I-OCAL DATE ISSUED 2 1O-5 [)IS-rwCT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s I-1EALTH (Complete in Triplicate) Application is hereby made to 'the'San Joaquin Local Health District for a permit to construct'and/or instal-1 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 Local Health District. Job Address �Q _ - A-T14PnrD Subdivision Name Owner's Name Address _�6p q g _ —a Phone Contractor's Name icense No. 7 6)U Phone ? } TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C0 PUMP INSTALILATION SYSTEM REPAIR ❑ OTHER ❑ f ~ -�` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i • 1NTENDED-US'E��= _ TYPC,OF'WEI"L "_'PROBLEM'AREA "'CONSTRUCTION SPECTfiCATIOIVS ❑ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation Q Domestic/Private ❑ Gravel Pack ❑Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing f❑ Irrigation Approx. ❑ Eastern Depth � Specifications ❑ Cathodic Protection Depth of Grout Seal ❑ Geophysical Type of Grout Other Surface Seal Insta��yl�l+ed by Repair Work Oone Type of Pump �J(� H.P. State Work Done 5 Well Destruction U Well Diameter l Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is p available within 200 feet.) Installation will serve: Residence_ Commercial _ Other 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 PKG. TREATMENT PLT. ❑ Type/Mfg ; Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property line DESTRUCTION 1 LEACHING LINE LJ No. & Length of lines Total-length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number i SUMPS Distance to nearest: Well Foundation Property Line k 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 applicant must c 1 11 re fired inspections. Complete d w' reverse side. Signed X Title: v/ Date: F EPARTMENT USE ONLY. Application Accepted by Area �� ❑ Stk- 466-fi781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date c� Manteca 823-7104 Final Inspection by Date 3 /— Tracy 835-6385 Applicant - Return all copies(Z Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0, box 2009, Stk,, CA 96201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I -2rI� 3 EH 13-24 REV. 10/82 10/82 500 14-26