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c APPLICATION FOR'PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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 Local Health District. Job Address ,lo.vrirlcA Qt) -^ Subdivision Name Owner's Name (,by �.& T Address Phone Contractor's Name �� —j--�_I.yr� License No. A2irt � - - Phone StrX gV,.rr TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F-1 DESTRUCTION PUMP INSTACLATI'ON`11' S7STEM-REPAIR— DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. I 1� Industrial E]Open Bottom E] Manteca Dia, of Well Excavation ' 1 U Domestic/Private E]Gravel Pack Q Tracy Dia, of Well Casing f;< ' 'r Public F—�Other ❑ Delta Type of Casing U Irrigation Approx. Ej Eastern F Cathodic ProtectiSpecifications on �, Depth 'a _. } Depth of Grout Seal Geophysica] Type of Grout i Dther ...,„., „ .Surface.Seal,.Instal l ed bye Repair Work Done 0 Type of Pump H.P. State Work Done ',-,_- _. .. ,._.. e Well Destruction Ej Well Diameter" Sealing Material-,(top 50') + Depth a Filler Material (Below 50') 6— —TYPE OF.SEPTIC WORK:,,,NEW=INSTALLATION. REPAIR/ADDITION- . U�=(No,septicYtank-or.,seepage.pi.t permitted4i,fTpublicsewer"i-s-4..,...�=�•�� available ithin 200 feet.) (� Installation will serve: 11' esidence Commercial _ Othert'` —�`` Number of living units: _,tj_ Number of bedrooms _ Lot size Character of soil to a depth of 3 feet: _ �Q a � �` Water table depth SEPTIC TANK . Type/Mfg Capacity i L Nott Compartments ( PKG. TREATMENT PLT. Ej Type/Mfg Capac4ty ' ,` r; Method-of Disposal i 4 SEWAGE SYSTEM Distance to nearest: Well 14V 4— Foundatio-rr;.'�e*r�`' Property Line t DESTRUCTION ❑ 11 # LEACHING LINE No} & Length of lines /— Total length/size FILTER BED `l Distance to nearest: Well^ ty Line 7-- SEEPAGE SEEPAGE PITS t ❑ Depth l Size Number q ' SUMPS IJ Distance to nearest: Well Foundation -_ "`b Property Line DISPOSAL PONDS ED 1 F - • a I hereby certify that I have`prepared this application and that the work willlbe done in accordance with San Joaquin county - ordinances, state laws, and rules and regulatMns of-the San Joaquin igcal--Health Districts Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this I 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 compensatipnlasysro1bCaNifornia." ' The applicant must call fqr all uire spections. Complete drawing on reverse side. =°. Signed X " Title: ��.�a�C_./( Date: FOR' EPAR T USE ONLY rt I 1 Application•'Accepted by _ Area Stk 466-6781 Additional Comments: # Lodi 369-3621 Pit or Grout Inspection by Date i f Manteca 823-7104 .� Final Inspection by Date Tracy 835-6385 b. Applicant - Return. all copies to: Environments lth Permit/Services-16b1 ;E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVE6 BY DATE PERMIT NO. INFOLA TREY. 14-26. _ -