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APPLICATION FOR PERMIT SAN JOAQLIN LOCAL HE4`IH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 465-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 3 (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_ rlyry�-L .s' 4&��— Subdivision Name Owner's Name C'#9 Address Ro, Phone Contractor's Namelocza,,6—nieLicense No. Phone yr`y }C TYPE. OF WELL/PUMP WORK: NEW WELL- WELL REPLACEMENT C] -DE•STRUCT-ION U W PUMP INSTALLAT'I'ON ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industria],.-; ', Open Bottom Manteca k U P 1� .Y 5 Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy J Dia, of Well Casing Public Other Delta Type of Cesing V Irrigation Approx. Eastern ' F—ISpecifications Cathodic Protection Depth S p Depth of Grout Seal 1-7 Geophysical : C]Other Type of Grout Repair Work Done Type of Pump Surface $eal i Installed by H.P. State Work Done_ Well Destruction U Well Diameter Sealing Material (top 501) 3 Depth -*Filler Material (Below 50') 77 TYPEOFSEPTIC WORK: NEW INSTRLLATIONi RE$AIi2/IADDITION J {No septic -if public—sewer is s.� Installation will serve: Residence Commercial tOther available within 200 feet.) t Number of living units: Number of`iedrooms o Lot size c�-- _ 4 Water table depth J` Character of soil to a depth of 3 feet: ,� SEPTIC TANK El Type/Mfg Capacity : No. Compartments k PKG. TREATMENT PLT. Ef Type/Mfg Capacity Method of Disposal . SEWAGE SYSTEM LDistance to nearest: Well N Foundation - DESTRUCTION Property Line _ao LEACHING LINE ,,. No. & Length of lines: ~ Total length/size FILTER BED ❑ Distance to nearest: , Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: : Well Foundation Property Line DISPOSAL PONDS ED I hereby certify that I have prepared this appli'tation and that the work'�will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin.Locdl 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 becgme subject-to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifles the following: "I certify that in the performance of the work for which this permit is issued, I shall employ 0ersons subject to workman's compensation laws of California." .r The applicant must callfor 11 uired i spec ns. Complete drawing on reverse side. Signed X Title. Date,. FOR DEPARTMENT USE,QNLY Application Accepted by , . Area [f Stk 4'66-6781 Additional Comments: k Lodi ,,...-369-3621 Pit or Grout Inspection by Date Manteca 823-7104 C''G Final Inspection by J Date �'� Tracy 835-6385 Applicant - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S � FEE BASE AMOUNT, DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO k - - - S lad EH-13-24;. REV. 10/k' $ - 10/82 500 14-26