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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT jjT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _-33-13 -7 Telephone (209) 466-6781 DATE ISSUED ) N PERMIT,EXPIRES 1 YEAR FROM DATE ISSUED (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 Re-u7llations the San Joaqu'n Local Health District. Job Address 0 Subdivision Name Owner's Name Address rp ,>p �` ed{dD Contractor's Name !1S S License NO_4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �` W W .1 - -` - PUMP INSTALLATID'I!U-1/- SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK & SEWER LINES 0—T G DISPOSAL FLD. PROP. LINE O � FOUNDATION3.jj�0- 7 'AGRICULTURE WELL — OTHER WELL PITS/SUMPS TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial Ef Open.Bottom ❑Manteca Dia. of Well Excavation �� w ❑ Domestic/Privateravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection ^Depth— ❑Geophysical ,Y Depth offGGrout Seal t� R' ❑Other ! _ rout Surface Seal Installed by ��f�jls"{} ��E�S/��///� Repair Work Done [] Type of Pump s: Z'a4 14,P. ,� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is (� available within 200 feet.) " Installation will serve: Residence _ Commercial _ Other [ J � R 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 SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No':. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to"nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 applic mu t c 11 for all required inspections. Complete drawing on reverse side. Signed X le: , �,��' > Oate: a SAu ENT l ONLY - Application Acceptey Area ❑ Stk 466-6781 Additional Comments. ❑ Lodi 369-3621 Pit or Grout Inspection y Date t2 �� 3 _�s Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ` EH 13-24 REV. 10/82 10/82 500 14-26