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i APPLICATION FOR.?ERM;T SAN JDAQLiN LOCAL iicALTH DIsAN _ i r, q k 1601 E. HAZELTON AVE., STOCKTON, CA "t1lY �} �� s_� PERMIT NO. VA `�`1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE I;MN JOAQUIN LOCAL DATE ISSUED (Complete in Triplicate) �- DISTMOT Application is hereby made to the' San Joaquin LOCdl Health District for a permit tar construct and/or install the work herein k described. Thisapplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rulesrra��nd Regula't�ions of ;the San oaquin Local Health District.. P_ 411 Job Address p( I ^ Z-• joA rSubdCi�vision Name Owner's Name Address J/ Ih Phone �- Contractor's Name .LJ. License No. ��!(}/O Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑{ DESTRUCTION ❑ PUMP IN5TALLATION ❑ SYSTEM"REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES ,+t,_ DISPOSAL FLO. PROP. LINE FOUNDATION ;I AGRICULTURE4WELC r OTHER�WEL�-�' PITS/SUMPS W INTENDED USE TYPE'OF WELL PROBLEM AREA '" CONSTRUCTION SPECIFICATIONS �rJ- Industrial I ❑ Open'Bottom []Manteca Dia.1,of WeTi-Excavation y) Domestic/Private Q Gravel Pack ❑ Tracy Dia, of Well Casing 1- ❑ Put,-" --. __,_.�.r '❑Other ❑ Delta _ Type of Cas`q s ❑ Irrigation JJpprox. Eastern ❑ Specfaca'tions ' ^ ❑ Cathodic Protection rDe th p Depto of-Grout Seal' ❑ Geophysical `-Y Type of Grout Other ' 5 . -Surface SeallInstalled by Repair Work Done Type of Pump �t H:P.' ' �' '` 'state Work-Done in C Well Destruction ❑ Well Diameter Sealing Material (top 5e') t __..Depth Filler Material (Below 50') y TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is va-flable-wi-thin--2.00-feet.• V F, Inst `lotion wi,ll ,serve.: Residence Commercial_ Other j Number of living units: l 'Numbero f bedrooms Lot size J. Character of soil to a depth of 3 feet: '�'> 5 ��' F` ' :^ .��Iater table depth i SEPTIC TANK ❑ Type/Mfg j -- Capacityk- No. Compartments r: PKG. TREATMENT PLT. ❑ Type/Mfg �.a Capacity ' Y_ 'Method of Disposal r SEWAGE SYSTEM Distance to nearesii 14fe11 -� -�Foundati' ? Property Line } DESTRUCTION ❑ i E LEACHING LINE E❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line g SEEPAGE PITS 4 ❑- Depth V Size Number SUMPS Distance to nearest: Well Foundation Property Line " U s i 015P05AL PONDS-` ❑ l ! r € I hereby certify that I have prepared this application and that the work will be done ih accordance with San'Joa_q'i' county 5: 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 k this permit is issued, I shal en)ploy persons subject to workman's compensation laws of California." I The a'ppli ust call for 1 ired inspections. Complete draw' on reverse side: .7 Signed X Title: Date: ` r 0 EPARTM T USE ON Application Accepted by l t/ .ter -S� Area �.. ❑ Stk 466=6781 Additional Comments: A Lodi 369-3621 ', Pit or Grout Inspection by..`, Date Manteca 823-7104 J Final Inspection by I'; Date ❑ Tracy 835-6385 'Applicant -. Return all c s to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ,Box 2009, Stk., CA 95201 rINFO BASE AMOUNT'IDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. S d o VS/111 g�-1 EH 13-24 REV. 10/82 10/82 500 q 14-26 '