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F ' J� APPLICATION FOR PERMIT F, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EgPIRES I 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 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 rL�ocal Health District. Job Address � 'f�' C AF 7) 4;7/F </' Z:) Subdivision Name Owner's Name /�af�/f., %.� Sf2r�' /.1C Address y Phone /- ':Z Contractor's Name %rf�O��rifJ�/ = w'''`''j�/Lir�egse NoPhone TYPE OF WELL/PUMP WORK: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION T SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation EJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other I EJ Delta Type of Casing Lj Irrigation Approx_ EJ Eastern Specifications Cathodic Protection Depth ^}+� Depth of Grout Seal 1-1 Geophysical Type of Grout Q Other Surface Seal InstallOo b . Q Repair Work Done ❑ Type of PumpH.P. I �� State Work Done IIIc kv, I i • + Well Destruction ❑ Well Diameter.1 Sealing Material (top 509 Depth 1 Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION F-1REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 11 available within 200 feet.) ; Installation will serve: Residence — Commercial _ Other Number of living units: Number of bedrooms Lot size Character of sail to a depth of 3 Water table depth feet: y SEPTIC TANK ❑ Type/Mfg ! Capacity No. Compartments 1 PKG. TREATMENT PLT. [] Type/Mfg , Capacity Method of Disposal A SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE [J No_ & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [] Depth f Size Number SUMPS LI . Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS 4 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. , forrtrance of the work for which this Home owner or licensed agent's signature certifies the following: "I certify that in the per 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 aPP lican � -ca fo ;,.requid inspections. Complete d yn reverie side_ : Datel Signed X fre � �'�� Title: ,�/ FOR DEPARTMENT USE ONLY Stk 466-6181 Application Accepted�y.� � Area Lodi 369-3621 Additional Comments: 1 Pit or Grout Inspection by.t Date Manteca 823-7104 >, Tracy 835-6385 Final Inspection by Date Applicant - Return all copies to:.JEnv nmental.Health Permit/Services 1601 E. Hazeltob Ave., P.O. Box 2009, Stk., CA 95201 r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/B2`fS00 EH 13-24 REV. 10/82 14-26