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c a APPLICATION FOFOR � �33 . � LICATIOi Ri•iiT SAN JOAQUiN LOCAL HE LTH DISTRICT 15CI E. HAZELTON AVE., STOCKTON, CA PERMIT NO. y Telephone (209) 466-6781 LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rt `� DATE ISSUED 3— 0 Ap- (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 fa described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump N and the Rules and Regulations of the San7 Joaquin Local Health District. S,r/N Job AddressZSlon S. 11L�}�L1e,2 1G�Latat"3 Subdivision Name T Owner's Name Address Phone Contractor's Name License No. 7 7 Phone 3 3 N� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U ~� S 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 SPECIFICATIONS Industrial_ ❑Open Bottom Mantec. y _ . Dia.,of. Well. Excavation Domestic/Private F-1GravelPack Tracy Dia. of Well Casing �] Public ❑ Other ❑ Detlta Type of Casing �j Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump fi.P. State Work Done 'v,, Well Destruction ❑ Well Diameter Sealing Material (top 50') _ h Depth Filler Material (Below 50') S TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITION ❑ (No septic tank or seepage pit permitted if public sewer is C available within 200 feet.) 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 F, Type/Mfg v Capacity /�C3 No. Compartments PKG. TREATMENT PLT, Type/Mfg\\\ Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 0o Foundation Property Line DESTRUCTION ❑ LEACHING LINE ' No. & Length of lines -A I—o " Total length/size '71 7L a FILTER BED Distance to nearest: Well U U Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ` SUMPS L_J. . _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 workmant 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 . issued, I shall employ persons subject to workman's compensation laws of California." The applican must call far ll required inspections. Complete drawing on reverse side. ��_�s Signed X Title: Date: C! F DEP AccARTMENT USE ONLY A ication d by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date '1�Manteca 823-7104 Final Inspection by Date r ❑ Tracy 835-6385 Applicant - Return all cop- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY !rDATE PERMIT NO. INFO 4 q,5 00 EH 13-24 REV. 10/82 10/82 500 14-26