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APPLICATION FOR PERMIT SAN JOAQ IN LOCAL HEALTH DISTRICT �{ 1601 E. HAZELTON AVE., STOCKTON, CA I PERMIT N0. ' Telephone (209) 466-6781 /J DATE ISSUED. 1 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) F Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein E 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 s2 _ Subdivision Name Owner's Name �GrE4A 4,7), � � _� Address r Phone Contractor's Name _r-=" VD G ,LAJ#0D License No. 'y L {, Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT"❑` DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I ',' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION,—.'-�. .i°--, AGRICULTUREWWELL_._-,.,,.,,, OTHER WELL PITS/SUMPS INTENDED USE t TYPE OF WELLPROBLEM'AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ,:� ;❑y6pen Bottom []Manteca Dia. of .Well Excavation-*" ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing E] Public j Other ❑ Delta Irrigation I' Type of Casing F I LJ 9 Approx. EJ, Specifications ❑Cathodic Protection T :...Depth,,.__ ..-. ❑ k Depth of Grout Seal Geophysical ❑ Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. s State Work Done d ' Well Destruction ❑ Well Diameterts --- _ -5ealing'Mdterial"(top 501) Depth "I Filler Material (Below 50') ;A TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No,septic tank or seepage pit permitted cif public sewer is �. +' available within 200'feet.) J Installation will serve: Residence _ Commercial _. Other. Y Number of living units: f Number of bedrooms Lot size - Character of,soil �VType/mfg epth of 34feet: `` Water table depth o�, SEPTIC TANK # :'( (� ?Capacity Z-+�(�_ No. Compartments 2 f' PKG. TREATMENT PLT. fT - ❑ ype/Mfg ; �Capacity Method of Disposal Distance{,to nearest: Well �- Foundation �jfL` Property Line `3rj i — LEACHING LINE No. & Lerigth of lines YA,,V 1 Total length/size FILTER BED ❑ Distance'to nearest: Well Foundations Property Line0 SEEPAGE PITS Depth ;+y�1, Size zj Number SUMPS ❑ Distance'to nearest: Well Foundation '3(� Property Line ��Z }} 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. -# Homeowner or licensed agent's signature certifies the following: "I certify that .in the performance of the work for which this 1 permit is issued, I shall not employ any person in such mariner as to become subject to workman§ compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 call for 11 required spections. Complete drawin on reverse side. Signed X i Title: r - �a -Date: D RTMENT USE ON Application Accepted by Area �)-I " >tStk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by fm Date -Y ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835.6385 i Applicant - Return all copies to: Environmental Hea1.t7Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE BASE AMOUNT DUE'' A AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 . 10/82 500 14-26 y