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t APPLICATION FOR PERMIT ., ! SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON: CA PERMIT N0. J [I Telephone (209) 466-6781 DATE ISSUED } k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I *P ! i�( (Complete in Triplicate) Application is hereby made to the San Joaquin r Local Health District for permit to construct and/or install the work herein described. This application is maddlin compliance with San Joaquir County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an Regulations-OJf the:San Jo quin Local Health District., Job Address C�✓f } �-Subdivision Name Owner's Nam ' Address s � Phone License No. Phone -r mom s Contractor`s=Nam TYPE,OF WELL/PUMP WORK: NEW WELL ❑ _ WELL REPLACEMENT DESTRUCTION ❑ '+:a '�+ -PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISPOSAL FLD. PROP. LINE .'I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL '.t OTHER WELL PITS/SUMP5 INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS 1 IJ Industrial Open Bottom Manteca ,y Dia. of Well Excavation is Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑Tracy ff E Public ❑ Other, ❑ Delta err Type of Casing Irrigation Approx. ❑ Eastern J Specifications bepth / E] Cathodic Protection F 4-)' Depth of Grout Seal Geophysical 1 Type Grout ❑Other � * } Surface ceof¢Seal Installed by �J g H.P. ,( � t 4-;State-Work Done n � Repair Work Done L] Type of Pump i Seal in Material (top 50'.) �'— Well Destruction ❑ Well Diameter 9f ' Depth _ Filler;Material (Below 50� sewer TYPE OF SEPTIC WORK: NEW INSTALLATION }�� REPAIR/ADDITION o septic tank or seepage pit availabl ewithinu200cfeet.) is Installation will serve: Residence �Commercial,r Other Number of b rooms/ �Loti size Number of living units: := � ,..,. Water table depth Character of soil to a'depth,of 3 feet: y ❑ `Type/Mfg .c. Capacity No. Compartments SEPTIC TANK k Capacity Method of Disposal F-1 = PKG. TREATMENT PLT. � Type/Mfg " 1 SEWAGE SYSTEM Distance to nearest: Well.. _ Foundation__ Property Line DESTRUCTION LEACHING LINE No. & Length-6f Vines`-' 't _.l.e�rigth/size Total FILTER BED ' ,❑_ D.i•stancP nearest: Well '_ ndation P operty Li Number SEEPAGE PITS A ➢epth I size �j _ (� FoundationProperty Line S SUMPS U Distance'to nearest: Well ,. DISPOSAL PONDS CI 1 1 hereby certify that I have prepared this application and that the work will be done7in accor3ance withfSan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local,Health in t`ricterformance of the work for which this Home owner or licensed agent's signature certifies the following: "I -certify that in o wor permit is issued, S 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- n,the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California."' y The applicant t call fo 11 equired inspections, Complete drawing n erse'sid�: Date: Signed X Title: . ; PARTMENT USE ONLY Stk 466-6781 Applica i Accepted hF Area / ❑ Lodi 369-3621 Additional Comments: Daae ❑ Manteca 8237104 Pit or Grout Inspection by %b 835-6385 �1, ✓r�/'s - � 3 ,. -"'� Tracy-- Final "Inspection y Applicant - Return all copies to: Envi-ronmenntal Health Permit/Services 1601 EN azelton Ave., P.O. Box 2009; St k., CR 95201 RMOUWT REMITTED RECEIVED BY DATE PERMIT NO. _E.EE.- -. BASE __ AMOUNT.,DUE_. INFO f i' 10/62 500 EH 13-24 REV. 10/82 14-26