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APPLICATION FOR PERMMIT ` SAN JGAQll!N LOCAL iEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) ce7 0 1Z:1ee.CrZ4 PERMIT NO. DATE ISSUED 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,q¢ &e San oaquin 1,Qca1 Health District. < Job Address Jf� Subdivision Name Owner's Name ' r f1 Addressu%�_r3l ! = Phone Contractor's Name 1 1-jre.1 1l License No. + ,,% Phone � � 5 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT X / DESTRUCTION. U `PUMP INSTALLATION h(l SYSTEM REPAIR �`C� OTHER DISTANCE TO NEAREST: SEPTIC TANK T(J{+ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Industrial U Open Bottom Q -Manteca Dia, of Well Excayation ✓r Domestic/Private Gravel Pack [j Tracy Dia. of Well Casl'ng �] Public Other Delta th Type of !'Casing F _ tF3 LjIrrigation a Approx. " Q Eastern Cathodic Protection Depth i. Specifications Depth of Grout Seal Geophysical 4 F r 1 { „ Type of Groutr/1 :•' U Other Surface Seal Installed by Y; Repair Work Done Type of Pump T2"�a H.P. �._.l:State Work Done Well Destructi6h Well Diameter to'_Sealing Material (top 50') Gt�im�ti _ Depth L Filler Material (Below 50') P ✓� TYPE'OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No"septic tank or seepage pit permitted if public sewer is 1,.1 = available within 200 feet.) Installation`will serve: Residence _� Commercial _ Other t 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. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM�-1 Distance to nearest: Well Foundation Property -Line .- DESTRUCTION CI LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth Size Number SUMPS Distance to nearest: Well Foundation Property -Line DISPOS 11 PONDS w 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 hirin oY� su -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is is ued Iys 11 ealploy persons subject to workman's compens on laws of California." The applicant m 1 f al f q inspections. Complete drawing verse side..` /,? Signed X Title: Date: r. C25 R DEPARTME USEAV � {% Application Accepted by 2ifrea fJ 5tk 466-6781 Additional Comments: [] Lodi 369-3621 1� Pit or Grout Inspection by Date v ^ Manteca 823-7104 ,Applicant Final Inspection by Date /�] �?.�/ ❑ Tracy 835-6385 - Return all copies'to: Environ tal Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201IVI FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO -E L�►n f �•,t3 XV EH 13-24 REV. 10/82 ! O u 10/82 500 14-26 f _ �/ _ _ ► ti � � ,�/1 _