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f APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT J I N 2 P 1933 ,p 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 C�'y�7 •�.;��,�� DATE ISSUED a�+3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEkElFAL IA DISTRICT (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 Local Health District. Job Address -TIP F Subdivision Name Irrigation Owner's Name .Jvk El li bi�2 :5 Address A9" gsuz" 1�jJ_ Phone -„ 1 Contractor's Name L License No. e7t-, Phone C9 �` ❑ Other TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Depth Filler Material (Below 50') f i DISTANCE TO NEAREST: SEPTIC TANK TYPE OF SEPTIC WORK: NEW INSTALLATIONY,j_i'00 REPAIR/ADDITION F—I\(No septic tank or seepage pit permitted if public sewer is SEWER LINES DISPOSAL FLD. PROP. LINE FQUNDATION,� YVy ,1.4ff..�AGRICULTURE WELL_ OTHER WELL . PITS/SUMPS INTENDED USE TYPE OF WELL AOBr LEM AR ❑ Industrial U Open Bottom ❑ Manteca Domestic/Privte IJ a ❑ Gravel Pack ❑ Tracy L❑ Public 0 h D It CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation — Dia. of Well Casing 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, 1 shall not employ any person in such manner as to became subject to workman s 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 applican ust call fo 11 required inspections. "Complete drawing on reverse side_ �• Sign ed X_ Title: TME S1E ONLY Application Accepte y Area Stk 466-6781 --- Additional CommentsLodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE BASE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO t �3I-q3- EH 13-24 REV. 10/82(� 10/82 500 14-26 F L_j t er ❑ e a Type of Casing Irrigation App rrqqx. ❑ Eastern Specifications Deptf� ❑ Cathodic Protection Depth of Grout Seal ❑ Geophysical Type of Grout ❑ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ WelI Diameter,_,. Sealing Material (top 501) Depth Filler Material (Below 50') f i TYPE OF SEPTIC WORK: NEW INSTALLATIONY,j_i'00 REPAIR/ADDITION F—I\(No septic tank or seepage pit permitted if public sewer is Installation will ' available within 200 feet:) serve': `Residence_ ` Commercial Other ri — .• +.. » ' •' 3 Number of living _ units: . Number of bedrooms. —rLot size, Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK f [i Type/Mfg ,JT •Capacity QOG�411# No. Compartments PKG. TREATMENT PLT. SEWAGE SYSTEM ❑ Type/Mfg 1Capacity Method of Disposal Well Property Line V Distance to nearest: "'Foundation DESTRUCTIONd r LEACHING LINE Length Length of lines 3 ., Total length/size % FILTER BED ❑ Distance to.,nearest: Wel 1, 1 !Foundation Property Line SEEPAGE PITS ❑ Depth 2�5 / Size -3;a" _ _ Number .3 SUMPS ❑ Distance to'nearest: Well i Foundation u Property,Line , DISPOSAL PONDS ❑ 1 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, 1 shall not employ any person in such manner as to became subject to workman s 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 applican ust call fo 11 required inspections. "Complete drawing on reverse side_ �• Sign ed X_ Title: TME S1E ONLY Application Accepte y Area Stk 466-6781 --- Additional CommentsLodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE BASE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO t �3I-q3- EH 13-24 REV. 10/82(� 10/82 500 14-26