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APPLICATION FOR PERMIT E SAN JOAQUiN LOCAL HEALTH DISTRI 1601 E. HAZELTON AVE., STOCKTON, \`j ,i �QC �� mIT N0. 03 Telephone (209) 466-6781 S�R�-DG ATE ISSUED p � PERMIT EXPIRES I YEAR FROM GATE ISSUED � s, D (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 San Joaquin Local Health District. Job Addresses ,^ p J no- ��F Subdivision Name ► -. . Owner's Name Address �1 {� " :"Phone Contractor's Name ( „[ - Q1C.4 fib/ License No, r "'.3 7J + - y,. Phone dG'r TYPE OF WELL/PUMP WORK: NF NEW WELL n /WELL REPLACEMENT w DESTRUCTION v PUMP INSTALLATION Imo/ SYSTEM REPAIR OTHER 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 �_J Id� trial- - -"U ppe`n eo'ftom-� D Ma"hteca '��ia'of Well -Excavafi6i� - Domestic/Private Q Gravel Pack ❑ Tracy Dia. of Well Casing Public IF-i Other ❑ Delta Type of Casing Lj Irrigation Rpprox, E] Eastern Depth Specifications Cathodic Protection Depth of Grout Seal Geophysical 'I Type of Grout Other LJ � Surface Seal Installed by Repair Work Done 0 Type of Pump / H.P. State Work Done Iii& b_f, L— Well Destruction ❑ Well Diameter Sealing Material (top 501) -/ - 'E Depth. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living unitsA Number of bedrooms Lot size Character of soil to a depth of 3 feet; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal. SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION �� V 'LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line '! SEEPAGE PITS EJ Depth Size ?_ Number Well SUMPS �� Distance to nearest: WelFoundation Property Line DISPOSAL PONDS ❑ l 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 4 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 drawing on reverse side. Signed X }Y1 _ Title: Date: a F R D MEN SE'ONLY Application Accepted by Area p --- �Stk 465-fi781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection y Date U Manteca 823-7104 E t-- Final Inspection by Date ❑ Tracy 8356386 . Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to; . Environmental FEE SE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATTEPERMIT NO. INFD �__BA 1-73 10/82 500 EH 13-24 REV. 10/82 i i. 14-26 - I