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APPLICATION FOR PERMITS" SAN JOAQLiN LOCAL HEALTH DISTRICT ]� I60I E. HA7ELTON AVE_ STOCKTON, CA PERMIT NO, 0-1 Telephone (209) 466-678.1 q ?� PERMIT EXPIRES 1 YEAR FROM GATE ISSDED 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 Regulations of the San Joaquin Local Health District. Job Address _V/p - Subdivision Name Owner's Name Address .31€1 Phone Contractor's Name . ' License No. Phone ' s. tra TYPE OF WELL/PUMP WORK: NEL! WELL ❑ WELL REPLACEMENT DESTRUCTION ❑j / „ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Vv DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITSgSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Vv Industrial ❑ Open Bottom [] Manteca Dia, of Well Excavation d Domestic/Private ❑ Gravel Park ❑ Tracy Dia! of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing F[ Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical .0 Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter .-Sealing Material (top 50') — Depth Filler Material (Below 50') V d TYPE OF SEPTIC WORK: NEW INSTALLATION ❑I REPAIR/ADDITION o septic tank or seepage pit permitted if public sewer is r available within 200 feet.) v , Installation will serve, R �dence �mmercial _ Other Number of living units: Number of bedrooms T Lot size ,� Character of soil to a depth of 3 feet: _ q,d Water table depth 90 SEPTIC TANK ❑ Type/Mfg Cayce , Capacityr„�wq No. Compartments �L PKG. TREATMENT PLT. ❑j Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance t nearest: ell ,Foundation Property Line DESTRUCTION OYO LEACHING LINE ❑ No. & Length of lines _ 304 -Total -length/size C7 0 } FILTER BED ❑ Distance to nearest: Well im� F Foundation Property Line SEEPAGE PITS D Depth 10 Size ZL X I o ly]Cl umber s SUMPS C4-- Distance to nearest:' well Foundation Property Line —�- DISPOSAL PONDS ❑ `" Thereby 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 workmanIs 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 emplo persons subject to workman's compensation laws of California." The applicant m all or 1 e ired inspections Complete drawing on reverse side. Signed X _ Title: ir(L Date: L 7" 0 ARTMENT USE ONLY Application Accepted by Area 1 -E ❑ 5tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by hate ❑ Tracy 835-6385 Applicant - Return all copies to: Envirenmertal Heal/ Permit/Services A01 E. Hazel teNf Rve., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED'BY DATE PERMIT N0, INFO r la -1 -F 3 33a EH 13-24 REV. 10/82 &�) 10/82 500 14-26 ,