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APPLICFTION FOR PERN-I'� r SAN JOAQI;iN LOCAL HEALTH ICT 1601 E. HAZELTON AVE', STOCKTON, CASEP 1 9 }gyp 9�p.3 PERMIT NO, (1 q Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DAT4 4AWM �,DJOAQ AL DATE ISSUED + (Complete in Triplicate) HEALTH US ICT 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 H)ea District. Job Address 4 // l� r� Subdivision Name $C/aLG Owner's Name L Address _1;4,7 -9-- Phone �r � Contractor's Name 'T CJA/ License No. T2 7 / (� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ] OTHER ❑ lr�V� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE lJ" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r0 II J Industrial ❑open Bottom ❑ Manteca Oia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing t ] ❑ Public ❑ Other ❑ Delta Type of Casing 11-' Irrigation Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done K Type of Pump 5 --- H.P. State Work Done 9QJ,2UtA_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is O available within 200 feet.) —� Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWA5E SYSTEM �- 1 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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 compensation laws of California." The applican st c 1 for all r it spections. Complete drawing on reverse side. p Signed X Title: Date: MENT US NLY Application Accepte by YArea _ ""_ ❑ Stk 4fi6-6781 Additional Comment - Q� l ❑ Lodi 369-3621 Pit or Grout Inspection by Da e Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return al] copi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FEEBASE AMOUNT DUI AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. C7 EH 13-24 REV. 1O/82 10/82 500 14-26