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i APPLICATION FOR RMIT it SAN JOAQUIN LOCAL HE .Th DISTRICT 1601 E. HAZELTON AVE. STOCKTON, CA PERMIT NO. Telephone (209) 166-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR )M DATE ISSUED (Complete in Tri icate) � - f Application is hereby made to the San Joaquin Local Health Dis ict for a permit to construct and/or install the work herein described. This application is made in compliance with San Jo akin County Ordinance No. 549 for sewage or No. 1862 for well/pump i and the Rules saan Regulations of the San Joaquin Local .Health i t. G� Job Address J 9��-r v+rv1 ' ('Sion ame Owner's Name Address Phone �` ` t� icense No. one Contractor's Name "_ - - �� Phd.---.--�-�� f TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACI ENT DESTRUCTION Eji.� we&s PUMP INSTALLATION ❑ SYSTEM REPA �! ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta it Type of Casing ---rte ' ❑ Irrigation Appro. �❑ Eastern Specifications � ❑ Cathodic Protection Depth Depth of Grout Seal a ❑ Geophysical Type of Grout ' ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destructtoon �Well-Diameter........Sealing Mater I (top 50,)r....... Depth Filler Materi (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION I , (No septic tank or seepage pit permitted if public sewer is ^� available within 200 feet.) Installation will serve: Residence 1Commercial 0 er Stix — Number of living units: Number of bedroomsta�.. I Lot size �) . Character of soil to a depth of 3 fee l-A - ' - fl Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i. PKG. TREATMENT PLT, � Type/Mfg � Capacity � Method of Disposal 1 SEWAGE SYSTEM Q Distance to nearest: Well Foundation Property Line 1 DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well E�oundation Property Line 4 SEEPAGE PITS [�} Depth Size Number h s SUMPS ❑ Distance to nearest: Well Foundation Property,,L6 e DISPOSAL PONDS ❑! I hereby certify that 1 have prepared this application and th #the work will be done in accordance with[San Joaquin county ordinances, state laws, and rules and regulations of the San oaquin Local Health District. Home owner or licensed agent's signature certifies the follo ng: "I certify that in the performance of the work for which this .a permit is issued, I shall not employ any person,in such mann( as to become subject toiworkman0 compensation laws of California." Contractor's hiring or sub-contracting signature certifies tF following: "I certify that in the*performance of the work for which this permit is issued, I shall employ persons subject to wor4 anyy's compensation laws o California." i The appli t must call f r 1 required inspecfipns. Compl{ a raw�ng onve�rse side. ► �"'� 1 Date: Signed T tie DEPARTMENT USE L466-6781 Application ❑ Application Accepted by Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by ! Dateanteca 823-7104 Final Inspe 'kcstion by _ Date S- -�8 ❑ Tracy 835-6385 Applicant - Retu4'all�c'opies to; Environmental Health Perm /Services 1601 E. Hazelto6 Ave., P.O. Box 2009, 5t k., CA 95201 [NF BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �� V '� • i7.� `. S� 10/82 500 EH 13-24 REV.F10/82� 14-26