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_ I APPLICATION FOR PERMi SAN JOAQUi" LOCAL HEALTH .,ISTRICT 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �q Telephone (209) 466-57B1 DATE ISSUED # 1- 0 PERMIT EXPIRES 1 YEAR FROM n4TE -ISSUED (Complete in Triplicate) x Application is hereby made to the San'Joaquin Loca1•Heal th District for a permit to construct and/or install the work herein described. This application 1�is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump P and the Rules and Regulations ff.o he Sari Joaquin Local Health District. Job Address �/ ,.�I. Subdivision Name Owner's Name Q Address 7Phone.. Contractor's Nam ) LC . '� .License No. Phone 1 Y � TYPE OF WELL/PUMP WORK: �N. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l 4 INTENDED USE J�TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �] Industrial ;I Open Bottom ❑ Manteca Dia. of Well Excavation ( .} U Domestic/Private Q Gravel Pack Tracy Dia. of Well Casing v Public❑ Other Delta ^ 1❑ ❑ Type of Casing Li Irrigation Q Approx. ❑ Eastern Cathodic Protection Depth Specifications ❑ I Depth of Grout!Seal Geophysical Type of Grout u Other Surface Seal Installed by f Repair Work Done L Type of Pump H-P: State Work Dane t Well Destruction LI Well Diameter Sealing'Material (top 50') Depth Filler Material (Below 50') F F - TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION ErzNo Septic tankor seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence -/- Commercial Other ' f Number,of living units: Number of bedrooms Lot;si'Zey �� `Character of soil to a depth of 3 feet: f i _ Water table depth �p SEPTIC TANK Type/Mfg c .Capacity No. Compartments PKG. TREATMENT PLT. Lj Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well —/Foundation PropertylLine ❑� DESTRUCTION. it LEACHING LINE No. & Length'of lines; Q Total length/srs� .Y19j FILTER BED ❑ Oi'stance to nearest:,.-Wel 1,i- �+ Foundation / ;Property Line _ F SEEPAGE PITS ❑ Depth ; size'� t Number SUMPS ❑ Distance to 0.eaarest: Well+ Foundation Property„Line DISPOSAL PONDS' I hereby certify that I have prepared this application and that.thepwork will be done in accordahce with San Joaquin County N ordinances,,state laws, and rules and regulations of!the-San Joaquin Local Health District. 1, ' 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 Taws of California.” Contractor's hiring or sub-contractingsignature 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." r The applica t must cal for.all required,inspections. Complete.1 an reverse side. Signed'X Title:- Date: FOR DEPARTMENT USE ONLY Stk 466-6781 Application AcceptedIby Area n_ Additional Comments: ) _ �' Lodi " 369-3621 r 7 Date ❑TManteca 823-7104 Pit or Grout Inspection b Final Inspection by II Date L Tracy 835-6385 III _':Av t �4.p.plicant,�Return._allmcopie to:.. EnvI�pea Healtkrmit�/Services+1501 E. Hazelton Ave:;" P.O Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY r DATE�� ?PERMIT NO. INFO -337 EH 13-24 REV. 10/82 �! 10/82 500 14-26