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ry APPLICATION FOR PERMIT SAN JOAQCiN LOCAL HEALTH DISTRICT 13I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 113(5-3 Telephone (209) 466-6781 DATE ISSUED — PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) _ Application is hereby made to the San Joaquin Local +H alth District fora permit to construct and/or install the work herein described. This application is made,in compliance with San Joaquir County Ordinance No. 549 for sewage or No,-1862 for well/pump and the. Rules nd Regulations .of the San Joaquin Local th District., Q # Subdivision Name Job Address l Owner's Name h Address f Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I I l DISTANCE TO NEAREST: SEPTIC TANK s(' /f SEWER LINES 1 DISPOSAL FLD.IQIQ PROP. LINE _-f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSrW INTENDED USE TYPL OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1! 1 17 Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private Gravel+ Pack ❑ Tracy Dia. of Well Casing ❑ Public Other] ❑ Delta Type of Casirg Irrigation f y o A++pprox. ❑ Eastern Specifications Cathodic Protection Y /--` Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout C 1L, E ❑Other Surface Seal Installed by Repair Work Done G 'Type of Pump H.P. State WorkL Done Well Destruction ❑ Well Diameter Sealing Material (top IL 50') Al — Depth Filler Material (Below TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 1 { f - �-x—�avai-lab)e within 200 feet.) Installation will serve: Residence _ Commercial Other !. Number of living units: ;'Number of bedrooms Lot size Character of soil to a depth of43 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity F Method of Disposal SEWAGE SYSTEM Ei Distance to nearest: Well. Foundation Property Line DESTRUCTION LEACHING LINE F-1No. & Length of lines Total length/size i FILTER BED ❑ Distancelto nearest: Well Foundation i,Property Line SEEPAGE PITS ❑ Depth i] Size Number SUMPS ❑ Distance'to nearest: Well Foundation may, Property Line I DISPOSAL PONDS ❑ � i 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 si ature certifies the following:" "I certify that in the performance of the work for which this permit is issued, shal in y e ons subject to workman's compensation laws of California." The app cal far req inspections. Complete drawi g an reverse side. Signed x Title: At �- Date: DEPARTMENT USE ONLY O / ❑ Stk 466-fi761 Application Accepted by A a <O Lodi 369-3621 Additional Comments: ❑ C 7104 Pit or Grout Inspection b ` date /yI� Manteca 823-6385 � Date �-� p�*`,�,—,�"❑' Tracy 835-6385 Final Inspection by VlnvaanM� Applicant -.Return all copies to: Eirices 1601 E. Hazelton Ave., P.O. Box 2009, St k., CR 95201 FEE BASE AMOUNT :DUE AMOUNT REMITTED RECEIVED BY DSA/TE`' q PERlMIT NO.2 INFO 10/82 500 EH 13.24 REV. 10/82 14-26 s