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APPLICATION FOR PERMIT , SAN JOAQLiN LOCAL HEALTH_DiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 5 g3 ' DATE ISSUED c7 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 Od ' 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. L va Job Address Al, 'PA T , S ubdivision Name . Owner's Name sd ddress g ?K0 ` Phone Contractor's Name ;�/�yj/j] , fin � License No. 47,iPhone i; TYPE OF WELL/PUMP WORK: NEW WELL w- WELL REPLACEMENT 0 DESTRUCTIONIJ PUMP INSTALLATION SYSTEM REPAIR OTHER U' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 1 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom F7 Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack [j Tracy Dia. of Well Casing tV ❑ PubliC Cj Other ❑ Delta Type of Casing Li irrigation Approx. Eastern Specifications ❑ Cathodic Protection { Depth Z 'Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done [JF Type of Pump H.P. State'Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') M Depth Filler Material (Below 50') ' c _ 2 � TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ly (No septic tank or seepage pit permitted if public sewer is " available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil t of 3 feet: Water table depth. SEPTIC TANK .mType/Mfg -*• - Capacity ` No. Compartments i PKG. TREATMENT.Pt Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest:. Well Foundation Property Line i DESTRUCTION � 9 (yy Total length/size B LEACHING LINE No. & Length of lines � ff FILTER BED Distance to nearest: Well VQ< Foundation a Property Line s ` t SEEPAGE PITS Depth Zng � = Size _-. if Number f vla SUMPS IJ Distance tv'nea-rest-. W611` 1 0p� Foundation Property Line _ k DISPOSAL PONDS I hereby certify that.I have prepared-this application and that the work willfbe 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 t compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance o 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 all required spections. Complete dr wing on reverse side. _ Signed X JO Title: Date:. . , DEPARTMENT USE ONLY c Application Accepted by t, Area �5tk 466-6781 Additional Comments: ❑ Lodi 369-3621 ' DateManteca 823-7104 Pit or Grout Inspection b 3 by Date Tracy 835-6385 Final Inspection Applicant - Return all copie Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f r� ` N 41 7-S g3 g � Y, L�-J LJ 10/82 500 EH 13-24 REV. 10/82 14-26