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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT a S 1601 E. HAZELTON AVE., STOCKTON, CAPERMIT NO. � f Telephone (209) 4156-6781 • T r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED *#( )-1 (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�Sran Joaquin Local Health District, Job Address �1 � .S/ e A, 'CCq Rte, Subdivision Name Owner's Name F®`Ciir 12--S&f a Tr. Address Ph etee 6•� r�Z�� j Contractor's Name License No, Phone 9^- TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION 1 PUMP INSTALLATION SYSTEM REPAIR OTHER U fU'� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE V �r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FI Industrial U Open Bottom F7 Manteca Dia. of Well Excavation i LJ Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing , D Public [-1 Other El Delta Type of Casing n L_iIrrigation Approx. E] Eastern Specifications. ❑Cathodic Protection Depth Depth of Grout Seal ! Geophysical Type of Grout Other Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is }(G7�t� available within 200 feet:} Installation will serve: Residence Commercial _ Other !MgL Number of living units-. Z__ Number of bedrooms Lot size Character of sail to'a depth of 3 feet: �trr4 v` Water table depth 4 SEPTIC TANK ' �. -Type/Mfg Capacity 0 No. Compartments J PKG. TREATMENT PLT. E] -Type/Mfg Capacity Method of Disposal — SEWAGE SYSTEM s Distance to nearest: Well a Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines 'Total length/size FILTER BED Distance to nearest: Well �? Foundation rte, Property Line b A SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 workman5 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that J n, the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete draw jng on reverse side. Signed X 1 � N Title: Oate:�/r2 R USE ONLY .Application Accepted !P� Area Std 466-6781 Additional Comments: Lodi 369-3621 Manteca 823-7104 I Pit or Grout Inspection by Date `` k Date l- 6�3 Q Tracy 835-6385 . Final Inspection by Applicant - Return all copi to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [F1EBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT,NO.NFO Ev12 � 10/82 500 EH'-13-24 REV. 10/82 14-26 I