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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH^DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Y 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 Loc2l al h��Di District Job Address Ag Q.g 7 , S — S 7;9Su-MR Name 4,V?-0 Owner's Name , :,M1 4_-nna P Address s, , ' Phone Contractor's Name —l� 1 •Li�_T� License No. , Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'DI STANCE-TO-NEAREST.-..SEPT-IC-TANK-- _ SEWER LINES ---'---_--.»--..- DISPOSAL-FLD. ^-- --- -PROP-.-L-INE ---=-- • --�- - -- - - FOUNDATION_ �.'-AGRICUI.TURE WELL ' . ' -OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy M..--• Dia-. of--Well-Casing ❑ Public CM Oth' .l-r .„4 ❑ Delta � i, ❑ Irrigation Approx. Type of Casing ❑ Eastern Cathodic Protection Depth Specifications ❑Geophysical T � �Depth or6.rau£-Sea I 3 11 Other + Type of Grout �`A:-Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, I State Work,Done 0 Well Destruction Well Diameter , 00 ❑ Sealing Material (top 50 ) , Depth Filler, Material (Below 50') i TY-PE OF SEPTIC--WORK:- NEW INSTALLATION REPAIR/ADD ITION U (No septi tank or se p g pit'permitted if public sewer is Installation will serve: Residence Ax/ Commercial _ Other available within 200 feet.) I Number of living units: _ Number of bedrooms :Lot size Character of soil to a depth of 3 feet: t t Water table depth 7— SEPTIC TANK Type/Mfg - a..1 i•.� -`� tCa acit KrP Y _ _ Na. Compartments PKG. TREATMENT PLT. Type/Mfg �- Capacity Method of Disposal L SEWAGE SYSTEM Distance to nearest: Well Foundation 1D'” Property Line d DESTRUCTION 11 # LEACHING LINE 5( No. & Length of lines �-1 A�"*V, `� Total length/size FILTER BED 0 Distance to nearest: Well r+ 1 Foundation_ 74//__7_Property Line SEEPAGE PITS ❑ Depth Size 1 Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Y s I hereby certify that I have prepared this application and thatlthe work willibe done in accordance with San Joaquin count ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, y 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 workmank 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.fo workman's compensation laws of California." The applicant must call for 11 uired inspections. Complete drawing on reverse side. Signed X_ i Title: Date: /—axs FOR DEPARTMENT USE ONLY { Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by bate ' \f 1� Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environ tal Health Permit/5er�ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO • e c5 S�� FsS mss—S Z EH 13-24 REV. 10/82 14-26 10/82 500