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} f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 �r PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED DATE ISSUED a t " (Complete in Triplicate) Application is hereby made to the'San Joaquin Local Health District for a permit to construct and/or install the workherein 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. Jab AddressT �" Owner's Name Address Phone 2 3 Contractor's Name L License No. p Phone c. .. Z��Z Cr/ EEHUMaaaam TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT ❑ [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFTCATTONS 1-1 Industrial ❑Open Bottom []Manteca Dial of Well Excavation ..A ❑ Domestic/Private Gravel Pack ❑ Tracy Dia%of.Well Casing 17 Pub]ic ❑Other ❑ Delta 11 ❑ IrrigationType of Casing Approx. ❑ Eastern 'I Cathodic Protection Depth Specifications i "'""" �""" """` '"❑ Depth of Grout Seal Geophysical � P 1 j (Other Type of Grout 'w Surface Seal.Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) e , Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No eptic tank'or seepage pit permitted if public sewer is Installation will serve: Residence l Commerciale Other r available within 200 feet.) Number of living units: Number of bedrooms Lot`size Character of soil to a depth of 3 feet: 6. Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity .Method of Disposal Distance to nearest: 'Well ` Foundation �5 Property Line 1 � a LEACHING LINE ❑ No. & Length of lines .i YI- Total length/size FILTER BED {❑ Distance to nearest: Well Foundation .1 (property Line i SEEPAGE PITS ] Depth �— Size Z�Aumber f _ T SUMPS ❑ Distance to nearest: Well /,:Z02 Foundat on /��"� A$ Property Line _rf3a"' DISPOSAL PONDS ❑ # "r, -� ) 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"I certify that in the performance%f the work for which this permit is issued, I shall not employ any person in such manner aslto 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 applicant must call f r all required inspections. Complete drawing on reverse side. , Signed X�� - Title: Date: � L F4 DEPARTMENT USE ONLY fk i Application Accepted by AreaStk •466-6781 Additional Comments: ID ❑ Lodi 369-3621 Pit-or Grout Inspection by Date EJ4-.Mdnteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmen Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. J INFO r EH 13-24 14-26 REV. 10/82 ��C7 10/82 500