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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 S_ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _!J—ko_�J1J— Telephone (209) 466-6781 GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) 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 Re�giulatio s of h San Joaquin Local Health District. Job Address cr© �� Subdivision Name Owner's Name Address Phone Contractor's Name mA W cense No. ii xx Phone 2 M TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y ,`r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 4��14''C/// DISTANCE TO NEAREST: SEPTIC TANK &�d)ag SEWER LINES DISPOSAL FLO. PROP. LINE _!�W r} FOUNDATION AGRICULTURE WELL _ OTHER WELL, PITS/SUMPS _l�Yli INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrialpen Bottom ❑Manteca Dia. of Well Excavation r- L_I Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing tk�ru_bIic ❑Other ❑ Delta Type of Casing L_fIrrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth ❑ /� Depth of Grout Seal Geophysical � ❑Other ��L,,sii rsF en., TYPe of Grout 1i�G .irsvw Surface Seal Installed by Repair Work DoneType of Pump ;F- H.P. State Work Done e1 A&V 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') Fi r Maer TYPE OF SEPTIC WORK: NLf INSTALLATI ❑ REPAIR/ADDITION [J- (No septic tank or seepage pit permitted /public sewer is �Gf available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 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 DESTRUCTION Q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `C 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 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 applica st cal required inspections. Complete drawin o reve se si e. Signed X YZ46 ` Date: FOR DEP TMEN UX 0 L Application Accepted b r 1- p Area `-t� ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-03621 Pit or Grout Inspectio by 4 Date ❑ Manteca 823-7104 Final Inspection by - O• � Date oet)�/� - ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0, INFO EH 13-24 REV. 10/82 g 0/82 500 14-26 i