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APPLICATION FOR.PERM;T i SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � Telephone (209) 465-6781 DATE ISSUED 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 madein 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 Lo al Health District. Job Address A212 y"t 00 sa Subdivision Name Owner's Name Address , ,'2_1 (r 3 /0),LY'I aot15CL Phone Contractor's Namerf License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR LJ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ' FOUNDATION =1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFsWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial U Open Bottom ❑ Manteca Dia. of,Well Excavation U Domestic/Private Gravel Pack R Tracy Dia, of Well Casing 117 Public Other E] Delta 11 Type of Casing V Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth 1-1 t Geophysical Depth of Grout Seal � Other Type of Grout Surface Seal Installed by Repair Work Done FJ Type of Pump H.P. State Work Done s Well Destruction U Well Diameter ;° Sealing Material (top 501) _ Depth i.j Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is ! I available within 200 feet.) Installation will serve: Residence _ Commercial _ Other a 4 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 ``feet: Water table depth SEPTIC TANK El Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg .1 Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: : Well Foundation Property Line DESTRUCTION E I LEACHING LINE U No. & Length of lines Total length/size FILTER BED F7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 must cal for a 1 red in ct'ons. Complete dr g on reverse side, Signed X 4 Title: Date: ;001 F R D E ONLY Application Accepted b Area Stk 466-6781 Additional Comme s: ' [] Lodi 369-3621 Pit or Grout Inspection by Date L J Manteca 823-7104 Final Inspection by ' / Date �} Tracy 835-6385 Applicant - Return all copies to: Environmental Health P rmit/Services 1601 E. Hazelton Ave., P.O. •Box 2009, Stk., CA 95201 FEE BASE -AMOUNT DUE AMOUNT-REMITTED. RECEIVED BY DATE PERMI11T N0. INFO O 3 f EH 13-24 REV. 10/82 10/82 500 14-26 i ... RkA