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¢ APPLICATION FOR PERMIT SAN JOAQL;" LOCAL HEALTH DISTRICT II � +, 1501 E. HA7ELTON AVE., STOCKTON, CA 01 E eo Telephone (209) 466-6781 PERMIT N0. — [ 1) Ia_fz PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSJED `�i (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/0 64sofJthe San Joaquin Local Health District. Job Address J /�A 't. n Subdivision Name Owner's Name f' 7' ( Phone Contractor's Name C.{1�1 f (� /� cense No. Phone TYPEOF WELL/PUMP WORK: NEWWELLWELL REPLACEMENT L] DESTRUCTION ❑OTHER U PUMP INS TR LAT SYSTEM REPAIR ❑� + 1 DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLO. PROP. LINE / FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS"d o INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indust ❑ Open Bottom Manteca S� Iwo ❑ Dia. of Well Excavation , ! - mestic/Private avel PackTrac ❑ Y Dia. of Well Casing � ❑ Public ❑ Other ❑ Delta ❑j IrrigationApprox. Eastern Type of Casing � � ❑ Cathodic Protection ♦Depth o Specifications qA i y ❑Geophysical # 3 t *Depth of'.Grout Sea] LJ OthersED Type of Grout ' l A 4� 'Surface Seal Installed by Repair Work Cone Tyte of Pump S �H:-P.r State Work DoneS [� Q Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) O TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1E (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence Commercial _J64her available within 200 feet.) Number of living units R Number oV bedrooms— Lot size Character of soil to a depth of 3�feet: � . ! '!. Water table depth SEPTIC TANK Type/Mfg�, 4.10 --4* OOpacity No. Compartments PKG. TREATMENT PLT. Type/Mfg J # T T � Capyacity Method of Disposal SEWAGE SYSTEM Di-stance-to.nearesu l Well Foundation Property Line DESTRUCTION ❑ LEACHING'LINE U No. & Length of lines Total length/size r FILTER BED Distance to nearest: Well f Foundation Property Zine ' SEEPAGE PITS Depth Size : Number SUMPS L_ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� ; 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 issue shall employ persons subject to workman s compensation laws of California." The ed X us ,c f requ red inspections. Complete=br reve �Signed K Title: ,�— Date: OR DE ARTMENT USE ONLY - Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by ' t Date !J / "� ❑ Manteca 823-7104 Final Inspection by Date /D -z(J —k� L Tracy 835-6385 Applicant - Return all copies to: vi onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO �- EH 13-24 REV. 10/82 14-26 10/82 500