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APPLICATION FOR PER SAN JOAQUiN LOCAL HEALTH ICT[j 1601 E. HAZELTON AVE., STOCKTON, CA" CT 41983 PERMIT NO. -$t-f Z-3 q 7 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM OAT L�' SSIJE01 U?N LOCAL DATE ISSUED � � �3 (Complete in Triplicatet TIA DIS RICA' ) ' i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein oQ described. This applicationis made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules;y`�Sand Relggulations of the San Joaquin Local Health Di trI t. .t 1 Job Address 06196 2,�Vl�� flrnh a�`��Jfc Owner's Name �..�, �, -fi..�.,.,�' Ad s Phone - Contractor's Name &2[13 �Aa License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER L} DISTANC€ TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing ❑'Irrigation Approx. ❑ Eastern Specifications i Cathodic Protection Depth ❑ � Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H,P. 2 State Work Done oWell Destruction U Well Diameter Sealing Material {top 50') !'.� _ Depth .k Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is S available within 200 feet.) -� f Installation will serve: "Residence _ Commercial Other Number of living units: Number of bedrooms Lot size i Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, [] Type/Mfg 1` Capacity Method of Disposal I SEWAGE SYSTEM Distance to nearest: Well Foundation property Line DESTRUCTION �� I LEACHING LINE L] 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 ll� DISPOSAL PONDS ❑ I hereby certify that 1 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 tc wcrkman� compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foxl'owing. "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 must all for al quired inspections. Complete drawing on reverse side. Signed XTitle: Date: ARTMENT U ' ONLY ❑ Application Accepted"by Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-1104 Final Inspection try Date /U�� 7� � Tracy 835-6385 Applicant - Return all copies to: nvironmental Health Permit/Services 1601 F. Hazelton Ave_ P.O. Box 2009, St k., CA 95201 3 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO IG/ �3--�0�171 EH 13-24 REV, 10/82 10/82 500 14-26 c> I