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t� APPLICATION FOR PERMIT TN DISTRICT _9 SAN JOAQUi'J LOCAL. HEAL 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED t i PERMIT EXPIRES 1 YEAR FROM GATE ISSUED ` �f (Complete in Triplicate) ict " Application is hereby made to the San Joaquin Local Health Distr .fora 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. Subdivision Name .- Job Address . J. Phone �],/Z,� ' Owner's Name; Ai �- Address Phone'?q,;) - 3 J�� I license Na. Contractors Name C � 1�-> TYPE OF WELL/PUMP WORK: NEW. WELL WELL REPLACEMENT j] DESTRUCTION ❑ i�. ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 LINES �T-- � FOUNDATION DISPOSAL FLD. PROP. LINE DISTANCE SEWER LITO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS +_ f ; I INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation � u� -- r�Gra�ei�P'�ckr cy Dia""of Wel l�Casing �► .U..Domestic/Private �l - f ` 1 F1 Other Delta Type of Casing j Public Approx. Eastern Irrigation c A pp t ❑ Specifications Depth Depth of Grout Seal �'Cath odi,c Protection _ ' Geophysical Type of Grout 4 ► KZ ❑Other Surface Seal Installed by — `_lk AState Work Done Repair Work Done ❑ Type of Pump H,P. . Well Destruction FJ0 Well Diameter Sealing Material (top 5501 f Filler Material (Below 50') ., Depth � -• ,. . •'"tea.:. - r TYPE OF SEPTIC WORK: NEW INSTALLATION (—I REPAIR/ADDITION ❑ {No septic tank or seepage p,avaiprmittlableewithd if inu200cfeel:sewA"' Other_ y Installation will serve: Residence Commercial_ , ° Lot size ti Number of living units: Number of bedrooms � Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANKI, F-1 Type/Mfg-- Capacity Capacity Method of Disposal PKG. TREATMENT.,,PLT. [1 Type/Mfg Property Line SEWAGE SYSTEM Distance to nearest: Well Foundation DESTRUCTION No. & Length of lines Total length/size LEACHING LINE U 9 Property Line FILTER BED Distance to nearest: Well Foundation P �---- Number SEEPAGE PITS ❑ _Depth - Size SUMPS-"'""" ' L1 Distance--rd'rA-ear est �11� "Foundation T DISPOSAL PONDS ED plication and that the work will be done in accordance with San Joaquin county I hereby certify that I have prepared this ap ;M ordinances, state laws, and rules and regulations of the San Joaquin Certifocal y that District, in istricperformance of the work for which this I Home owner or liyerSed agent's signature certifies the following: permit is issued, 1 shall not employ any person in such manner as to become subject to workman compensation laws of California. Contractor's hiring shall sub=contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." 1 The applicant must call for all requir d inspections. Complete drawing on reverse side. Date: x Signed X Title: DEPARTMENT USE ONLY } ❑AreaStk 466-6781 t �,/ Application Accepted•b) be F' coli 369-3621 Additional Comments: r� � «^ �"'" '� �' Date 3 Manteca 823-7104 Pit or Grout Inspection by ❑ Tracy 835-6385 Date Final Inspection by Applicant - Return all copies, to: ' Environmental Heal Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95 E. RECEIVED BY �DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED 10/82 500 EH. RV. 10/82 14- ►►V f "�