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AMIN qqpp }� a = A APPLICATION FOR PER�!T SAN JOAQUiN LOCA!. 'HEp,LTH :ii STRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERFIIT N0. 0 f AN J13A 'UIR" WCAL Telephone (209) 4666781. fI-9;ERL_FI l DI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete it 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 it 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 Address / W ' `V CM9 0 AAWWCAame Owner's Name --,QW Address- e Contractor's Name Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 74 EF SEWER LINES '� DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WELL �Z OTHER WELL PITS/SUMPS -� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom 'Manteca Dia. of Well Excavation Vmestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth----��Q-� y LJ Geophysical Depth of Grout Seal_ Other Type of Grout Surface Seal Installed by C Repair Work Done ❑ Type of Pump H, P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') r i .� unina nrirr.unraii TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK- , ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION Other Lot size Capacity Capacity Foundation _ Water table depth _ No.. Compartments _ Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ Number Foundation Property Line 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 workmant 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 applicanl_mu c 1 for 11 required inspections. Complete drawing on r verse side Signed X _i1/lJ4 Title: Date: FOR DE TM T USE ONLY Application Accepted by Area i 3 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date .Manteca 823-7104 Final Inspection by Date T lU ,Z —i k* ❑ Tracy 835-6385 Applicant - Return all copies to: Ervironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE [NFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. Lei el --33-9121 13 EH 13-24 REV. 10/82 10/82 500 14-26