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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 16Q1 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. ��Q Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) M 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 he San Joaquin Local Health District, Job Address 2 / Sr- Subdivision Name Owner's Name gPhone Contractor's Name T "}'SLicense No., Phone LLL--(Q —ge0457 lA7 TYPE OF WELL/PUMP WORK: NEW,WELL �L] WELL- REPLACEMENT --- C)E5TRUCTION PUMP INSTALLATION ❑ e SYSTEM REPAIR U OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALjFLD. PROP. LINE O rFOUNDATION AGRICULTURE WELL OTHER WELIL PITS/SUMPS INTENDED USE1' TYPE OF WELL PROBLEM AREA CQNSTRUCTION SPECIFICATIONS - f IndustrialOpen Bottom Man ❑ Manteca Dia. of Well Excavation Lf Domestic/Private. ' F7 Gravel Pack ❑ Tracy Dia. of Well Casing d �] Public ❑ Other ❑ Delta ` k Li Irrigation f^-----P�•—Approx7- E] Eastern Type of Casing Depth Specifications 1 ❑ Cathodic Protection p ( Depth of Grout Seal i 17 Geophysical } ¢ ❑Other ,- f t Type of Grout A, s +� Surface Seal Installed by , Repair Work Dane ❑ Type of.?Pump' iH,P. State Work Done ; Well Destruction ❑ Well Diameter - Sealing Material (top 501) Depth ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is l '* available within 200 feet.) ]nsta{11'ation will serve: Residence Commercial _ Other /. Number of livingunits: Number of bedrooms h' ` �» L-ot siie Character of soil to a depth'of 3?,feet; i Water table depth SEPTIC TANK Type/Mfg c�, Capacity / `'r No. Compartments __ p PKG. TREATMENT PLT. ❑ Type/Mfg Capacity �~ Method of Disposal i SEWAGE SYSTEM Distance ,to nearest: Well Foundation f Q r ;Property Line DESTRUCTION ❑ � t LEACHING LINE. ❑ No. & Length of lines Total length/,siie . FILTER BED ❑ Distance to nearest: Well Foundation 'Property'Line SEEPAGEIP [� Depth F „ E ' Size i t Number SUMPS ) ❑1 Distance to nearest: Well i ;Foundation Property Liney - DISPOSAL PONDS ❑ R 1 - r_ I A 1 #3 .1 "`; ' ` ' I hereby/Certifythat I have e r , n o . A 4 4f._ .prepared this application and that the work will be done in accordance with San Joaquin county' ordinances, state laws, and rules and regul.ations_4of',the San;Joaquin.Local Health District. J Home owner or licensed agent';-s signature certifies the foll'6wing: -"'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 hi 'ng or ,sub-contracting si ature certifies tFe'following: "I certify that in the performance of the work for which ., this permit i ssuea, I shall employ p ons subject to workman's compensation laws of California." The applzc �ll, for 11 requir dins ections'�Compl t g on reverse side. ' Signed X Title: fiL-�� _ Date: ! FO RTM T USE ONLY d Application A}ce'pted by I Area 02- ,'� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection byt Date ❑ Manteca 823-7104 Final Inspection by Date �� Tracy 835-6385 Applicant - Return all `copies 'to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE BASE AMOUNT DUE AMOUNT REMITTED RECLIVED BY DATE PERMIT NO. INFO EH 13-24 REV, 10/82 10/82 500 14-26