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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) " r 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 ulations of the San Joaquin Local Health District. Job Address � Q ?4�2 049t s 7 Subdivision Name t Owner's Name +„E(�L�,a,,t �2A Address' Phone Contractor's Name License No. Phone �j TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIA Q SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE .OF WELL! PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottoms F-1 Manteca Dia. of Well Excavation U Domestic/Private Gravel�Pack Tracy �Di•a"of Well,Casing Public EJ Other' Delta - } Type of Casing Irrigation Approx. Eastern ` Specifications I Cathodic Protection Depth Depth of Grout Seal Geophysical Other Type of Grout Surface Seal Installed by (� Repair Work Done 7 Type of,Pump H.P. State Work Done -� W Well Destruction ❑ Well Diameter Sealing Material (top 50') !-" 0q Depth filler Material- (Below 50') . R- TYPE OF SEPTIC WORK: NEW INSTALLATION 2EpAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is i I available within 200 feet.) Installation will serve: Residence -Ae-,Commercial. i Other # Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: 01M X791 Water table depth SEPTIC TANK Type/Mfg P. •Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg ; Capacity Method of Disposal , SEWAGE SYSTEM o Distance to nearest: Welloundation Property Line DESTRUCTION LEACHING LINE No. & Length of'lines Total length/size 1 FILTER BED E] Distance to nearest: Well Foundation Vt:n;PP Property Line SEEPAGE PITS ED Depth _rb/01— Size .f�/s(.'LL �� Number SUMPS Distance to nearest: Well jar 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 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 must call or a requ d inspections. Complete drawing on reverse side. w Signed X _ !' Title: a,4 Date: OR ARTMENT USE ONLY 01 Application Accepted by Area ❑ Stk 466-6781 Additional Comments: F-1 Lodi 369-3621 Pit or Grout Inspection by ""i Date Ll Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return all copies to: Enviroimenta ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED j RECEIVED'BY DATE. PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26