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APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, C.A., PERMIT NO. Telephone (209) 466-6781 1RDATE 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 i 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 Joaq uin Local Health District. Job Address `a_ _�,� .C�3TC�eO _`_Subdivision Name '< Owner's Name Address 9VO Phone Contractor's Name AA, No. Phone TYPE OF WELL/PUMP WORK: NEW WELL DWELL REPLACEMENT ❑ DESTRUCTION E] PUMP INSTALLATION ❑ kSYSTEM REPAIR "".❑'rt OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ f DISPOSAL FLD, PROP. LIKE € FOUNDATION AGRICULTURE WEL4' �, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBhM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Di a. of Well Excavation- Domestic/Private ❑Gravel Pack ❑ Tracy Dia: of Well Casing e ,1 x 1-1 Public ❑Other ❑ Dlta #...-...�.7y�e of Casing. �V Irrigation Approx. ❑ Eastern Specifioations%"k,: 1, ~ ❑ Cathodic Protection Depth •4-, �" ; # [6 *.1. Depth'of�Grnut,361 i ❑Geophysical e° �--_ Type of Grout ❑Other f Surface Seal' install ed,by Repair Work Done E] i Type of Pump H.P. Statelork.Done 1 t Q Well Destruction ❑ Well Diameter k Se`ling Material .(•top 501)._1 ,S. Depth }.Filler Mater•,ial.,{Below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION.❑ REPAIR/ 4D N,' s (No_,septic_tatnknor_seepage pit permitted if�pubjic sewer is m - ¢ 1 Y" available githin ADfeet.) � Installation williserve: Residence Commercial �' Sther- `� w :� _4 1 1 Number of living units: Nrber,of beVoo sLot�sizey • , , �' # I Character of soilto a depth of 3 feet,: Water table depth ,�.�( // F i SEPTIC TANK Type/Mfg I'; Lip -Capaci'. _ No. Compartments PKG. TREATMENT PLT.. ❑ Type/Mfg Ip u Capacity Method of-Disposal I SEWAGE SYSTEM r Distance to nearest: .Well _Foundation � Property Line DESTRUCTION LEACHING.JLINE ❑ No. & Length of lines -15tal'lengf6/size i FILTER 'BED ;� Distance to nearest: Weli O..._ Foundation o2 5 'r Property Line ,F SEEPAGE�PITS ;❑ Depth s. { Size Number E, @. SUMPS ; l ❑ Distance to nearest: Well x Foundation .- Property Line , DISPOSAL PONDS [] I hereby certify,.that I have prepared this application and that -the work will be done ifi accordance with San Joaquin county ordinances, state laws, and "rules and regulationsliof the San Joaquin Local Health District. f Home owner-or licensed agent's signature certifiesthe following: "I certify that in' the performance of the work for which this permit is issued, [?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`�halI employ persons subject to',workman's, compensat„on laws,of California4” The applicant must call oral requi` d inspections. Complete drawing on reverse side. t Signed X ,' "ekol �i' Title: y �wa�l �, Date: F9 EPARTMENT USE ONLY Application Accepted by4) 7 k ✓�-� Area ' ❑ Stk 466-6781 = f , Additional Cbmments: ��; ❑<-Ma di 369-3621 ! Pit or Grout 'rlspection b ''"` �) — .tib, ""Date- nteca--823-7104x_Final Inspection byDateacy 835=6385 Applicant me Return all copies to: En`viron` ntal Health Permit/Services '110'1E. Hazelton Ave.,�P.0,1Box.2009, Stk., CA 95201 t IM t FEE BASE f. AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a EH 13-24 REV. 10 82 s �I' .h , �� J ': 'i. 0/8 2 500 14-26 �� r. t ,•