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L 4 APPLICATION FOR PERMIT SAN JOAQLIN LOCAL HEALTH OiST 1601 E. HAZELTON AVE., STOCKT0� ,0 \?� % PERMIT N0. OJ V Telephone (209) 466-6781 !,. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �;.r, 3IJI3� � � DATE ISSUED _3 13Q[IS I (Complete in Triplicate) �' ,CIA 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 Address ZI7�'-3 "]. _ >�2yr,...r A Subdivision Name Owner's Name,,, - -s, Address x Lc� se��/ Phone rT Contractor's Name License No. yf��- 7 3 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN INTENDED USE . -TYPE-OF WEI-E- PROBLEM--AREA-- -_ --4aONSTRUCT-ION--SPECI:FICAT3oN5- IJ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑ Grav_el Pack ❑ Tracy Dia. of Well Casing O D Publics F—j Other Delta Type of Casing L, Irrigation Approx, Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Sear Geophysical Type of Grout D Other Surface Seal Installed by Repair Work Done Type of Pump �P. a3 State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth 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 available within 200 feet.) lJ" Installation will serve: Residence _ Commercial _ Other Number of living units: 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 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L 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-signa'tune'certifies'the'foll-owing--"I ceirtify`that-in-th7e-je-rformahce of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applic t must call r ll required i spections. Complete dr a 'ng on reverse side. a Signed X �� itIe: Date: -7—D R 0 DEPARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E4, lt.n Ave., P.O. Box 2009, Stk., CA 95201 [FEE BASE AMOUNT DUE AMOUNT REMITTED4ni5lml O EH 13-24 REV. 10/82 10/82 500 14-26