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APPLICATION FOR PERI;T SAN JOAQLit! LOCAI- HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, B V i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GATE 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 nd Regulations of the San J auin Local Health District. Job Address Subdivision Name Owner's Name Address Phone,?�25/—S 2111- ' Contractor's Na License No. ��(0 PhoneV��fj'-uS%O�"' TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ C)Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U w DISTANCE 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 O Industrial U Open Bottom [] Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta T irrigation Type of Casing Li 9 Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection p Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') Y fi TYPE OF SEPTIC WORK: NEW INSTALLATION�� pCommercial EAIR/ADDITION P (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Other Number of living units: Number of b yrooms Lot size /;r} 0-e4—A4 y° Character of soil to a depth of 3 feet: Water table depot �� f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J PKG. TREATMENT PLT. ❑ Type/Mfg - Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines'-- Total length/size FILTER BED ❑ DistanLe to nearest: Well Foundation Property Line SEEPAGE PITS 17 Depth _ Size l Number 7 SUMPS C1 Distance to nearest: Well 46fo Foundations_ Property Line DISPOSAL PONDS ❑ 111��\ 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 t 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 applican ust call r a required inspections. Complete drawing onJre se side. Q Signed X Title: / Date:J O FOR USE NLY Application Accepted by Area /� ❑ Stk 465-6781 i Additional Comments: le Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection byo _ Date 1 3 ❑ Tracy 835-6385 Applicant - Return all copies to: . Environment Health Permit/Services 1601 E, az ton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 481 S g , 3- 1011 EH 13-24 REV. 10/82 10/82 500 14-26