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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 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 Regulations of the San Joaquin Local Health District. ,lob Address 329Q_ Subdivision Name J Owner's Name F�"i Address 3 Phone �► Contractor's Name CA(,(,(/, y F License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK /�j(?-¢— SEWER LINES DISPOSAL FLD, /Ups fiPROP. LINE FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , Fr Domestic/Private Gravel Pack Tracy Dia. of-We11 Casing r v . ❑ Public ❑ Other ❑ Delta Type of Casing.-_PitC 16J2lL Irrigation 24W` Approx. ❑ Eastern Specifications* F-1CathodicProtection Depth . . Depth of Grout Seal ❑Geophysical Type of Grout FJ Other Surface-Sea°Installed by � /5, Repair Work Done ❑ Type of Pump " H.P. State Work Done Well Destruction ❑ Well Diameter_ Sealing Material�(top 50'),., Depth Filler Material/(Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ {Nonseptic tank or seepage pit permitted if pubtic7sewer is z i°fit;, available within 200'feet.) Installation will serve: Residence_ Commercial _ Other 1 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth F=, aSEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to"nearest: Well Foundation Property Line j DESTRUCTION LEACHING LINE ❑ No. & Length of.lines Total length/size " FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS. r—%I Depth Size Number SUMPS '" ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS %a.' 4, I hereby certify that 1 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 applicant ust ca for a 1 required inspections. Complete draw' g on ev se sid Signed X Title: Date: R DEPARTMENT USE ONLY 1: Application Accepted by "Area ❑ 5tk 456-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by 9/1 f7A1 Date �Ff ❑ Manteca 823-7104 Final Inspection by IDate ' ❑ 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 NO. INFO EH 13-24 REV. 10/82 10/82 500 14-2fi