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APPLICATION FOR PERMIT i SAN JOAQUiN LOCAL HEALTH DI 'F 1601 E, HAZELTON AVE., STOCKTON, CA AUG 2 PERMIT NO. M Telephone (209) 466-6781- PERMIT EXPIRES 1 YEAR FROM DATE 1S '� � � LOCAL. DATE ISSUED .r—�— -r..-r # / 14 �q ![LZ �_�v� (Complete in Triplicate) �ISTR C Z_23—Vty(� I 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—/3—5,blSubdivision Name Owner's Name Address '11( t -� , YYk frau__ Phone Contractor's Name License No. TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION l PUMP INSTALLATION SYSTEM REPAIR OTHERr .«- '�Er- � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I_J industrial U Open Bottom ❑Manteca Dia. of Well Excavation [1-Domestic/Private n Gravel Pack F—I Tracy Dia. of Well Casing 1] Public -J Other El Delta Type of Casing Ljlrrigation Approx. Eastern Specifications [Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout ED Other Surface Seal Inst lied by Repair Work Done % Type of Pump H.P. State Work Done BC",, Well Destruction U Well Diameter Sealing Material (top 50') M• -�'. per'` F 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,) Installation will serve: Residence _ Commercial Other rl Number of living units: Number of bedrooms Lot size ' l Character of soil to a depth of 3 feet: Water table depth 4 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 (� F DESTRUCTION 1, 1 LEACHING LINE U No. & Length of lines Total length/size FILTER BED r_� Distance to nearest: Well Foundation Property Line q SEEPAGE PITS F-1 Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line I& DISPOSAL 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 is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must 91T" r all required inspections. Complete dra 'nj on reverse side. Signed X , , [ d—�--� Title: Date:(�'�� OR DEPARTMENT USE ONLY AreaStk 466-6761 ❑ Application Accepted by _ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date .Manteca 823-7104 Final Inspection by _'r��`�1�jp,_ — — Date ❑ Tracy 835-6385 Applicant - Return all copies&/ Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FFEE � BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. EH 13-24 REV. 10/82 10/82 500 14-26