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APPLICATION FCR,PERMiT 0 SAN JOAQUiN LOCAL'HE4LTH OiST4RICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. Telephone (209) 466-6781' I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, DATE ISSUEp2-- (Complete in Triplicate) ' Application is,hereby made to the Sari 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 (egulations of._the San Joaquin Local Health District. t Job AddressA/j.,cgg Deg te R,P A^_y&"Subdivision Name I Owner's Name Address AP — P one Contractor's Name _�� cd��-� License No, Phone TYPE OF WELL/PUMP WORK: NE44 WELL 0 WELL REPLACEMENT DESTRUCTION ❑ C16 PUMP INSTALLATION SYSTEM REPAIR OTHER Ct-3 DISTANCE TO NEAREST: SEPTIC TANK FOUNI ffR,.LINES ' PROP. LINE 5 _ 1TION AGRICULTURE I WELL OTHER WELL PITS/5UMP5 W INTENDED USE TYPE OF WELL PROBLEM AREA = CONSTRUCTION SPECIFICATIONS 11 I I industrial } .., U Open BottomffManteca pia, of Well Excavation LJ Domestic/Private Gravel Pack Tracy- ti', i ❑ y ` ¢ Dia. of Well Casing •_ ; , 1] Public other Delta �! V Irrigation r ' ' Type-of Lasing; . . 1 ; Approx. E] Eastern �_, t Cathodic Protection- }-Depth ;, Specifications f ` Depth of Grout'Seal ' _ # f Geophysical — - U Other 'ti ;y v" Type"oJf,GroutA Surf aceFS'eal,Instalded b .,''. Repair Work Done Type of Pump: H.p, s� °Cr,.,i. State�Workpne Well Destruction U Well Diameter Sealing Material (top 50') "%4.c ' `Filler-Material (Below 50') 'TYPE OF SEPTIC'-WORK: -NEW INSTALLATION REPAIR/ADDITION b LI {No septic rtankMor seepage pit permitted. if publvc-sewer.is..— f Installation will serveavailable wifhin.,�200 feet,) :'LResidence Commercial Other Number of living units: " 1_'1' Number of bedrooms Lot size Character of soil to a depth of,3 feet: >/ i Water table depth 2 \ � e- SEPTIC TANK Type/Mfg � Capacity No. Compartments yr PKG. TREATMENT PLT.,r_1 Capacity Method of Disposal '* SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION i i x LEACHING'LINI ' "" No --&'L'engthi'of lIness�" - Total length/size .FILTER-B ED'� {. _ _ �Distance;to nearest; Well 4Foundation Property Line SEEPAGE PITS ❑ Depth; ' I „Y Size Number SUMPS L I Distance to nearest: Well Foundation Property Line F DISPOSAL PONDS f I hereby certify that I havere ared this a y p p pp`lication 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. i .{ 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 workmanK compensation laws.of Cal,ifornid�:" Contractor's hiring or sub-contracting signature certifies the following: "T certify that in the performance of the work for whichp this permit is issued, I shall employ persons subject to workman's compensation laws of California." ; The applicant must cal for a required inspections. Complete drawing on reverse side. li Signed X Title: Date: FOR'DEPARTME SSE ONLY t `' Application Accepted by r Area 5tk 466-6781 Additional Comments: ❑ Lodi 369-3621 } f Pit or Grout Inspection by l Date F� Manteca 823-7104 I Final Inspection by Date jC !d L Tracy 835-6385 i Applicant - Return all copies to; Environment ealth Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, 5t k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT N0. EH 13-24 REV. 10/82 14-26