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APPLICATION FOR'PERMIT 9 SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA / PERMIT NO. Telephone (209) 466-6781 fr DATE I55UE0 y 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 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 Address Z4{'S #"1»ST O1►� -_- Subdivision Name Owner's Name �pV �QR��CAL _ Address I 47-S9 40b&Phone Zl3 _91V Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION [] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION& 17 Industrial , U Open Bottom F-1Manteca Dia. of Well Excavation 17Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump i . H.P. State Work Done Well Destruction U Well Diameterl Sealing Material (top 501) Depth i Filler Material (Below 501) Q3 TYPE OF SEPTIC WORK: NEW INSTALLATION [J] REPAIR/ADDITION YJ (No septic tank or seepage pit permitted if public sewer is % s available within 200 feet.) Installation will serve: Residence Commercial _+Other Number of living units: Number of bedrooms Lot size Character of sol to a depth of 3 feet: T Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal y Distance to nearest: Well 0-101CL Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ { i 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 hir' g or sub-contracting sig natupt certifies the following: "I certify that in the performance of the work for which this permit is sued, I shall employ perso subject to workman's compensation laws of California." The applic all for req pec ions. Complet drawl r erse side. Signed Title: Date: R DEPARTMENT USE ONLY Application Accepted by Area Q ❑ Stk 466-6781 Additional Comments: r [rl ww sc� �� w-L'G ❑ Lodi 369-3621 Pit or Grout Inspection y Date ❑ Manteca 823-7104 Final Inspection •b •� Date j�,IQ�z ❑ Tracy 835-6385 t Applicant - Return all c es'to:l Env onme0gal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24" REV. 10/82 10/82 500 14-26