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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-678.1 ` PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED PERMIT NO. DATE ISSUED (Complete in Triplicate) I—? ( — 13 O — 6 tpplication'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. Job AddressSubdivision Name Owner's Name Address f Q 1 C1AIAJA RIfJfi, �/ . Phone Sd Contractor's Name License No. .3,�`$ ,fie 3 Phone y - R /`7 TYPE OF WELL/PUMP WORK: NEW WELL. L WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE1OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom (] Manteca Dia. of Well Excavation Domestic/Private �..J Gravel Pack Tracy Dia. of Well Lasing L* Public LJ Other Delta Irrigation Type of Casing Li 9 Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Ll Other � Type of Grout T Surface Seal Installed by Repair Work Done YJ Type of Pump J / N.P. I State Work Done Well Destruction LI Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION U (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 to a depth ofi3 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 LEACHING LINE EJ No. & Length of lines Total length/size FILTER BED F] Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth i Size Number Pili SUMPS a Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county �' F 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 I this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. F Signed X Title: �+ Date: FOR P RTS�{{ T USE ONLY „ ✓ Ap 1ication Accepted by �tm aJ, Area �$ - Stk 466-6781 Additional Comments: L Lodi 369-3621 Pit or Grout Inspection by Date L Manteca 823-7104 Final Inspection by Date In -11 — r1A -1 Tracy 835-6385 Applicant - Return all copies to:. Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Eh 13-24 REV. 10/82 10/82 500 14-26