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APPLICATION FOR PERI:i SAN OAQL-i' LOCA_ v:5!RICT 1601 E. HAZELTON AVE., STOCKTON, CA PFRMTT NO. � Telephone (209) 466-67$1 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM PATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/cr install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the Sn Joa uin Local Health District. i Job Address Subdivision Name Fi Owner's Name Address � ��/ � ,f � Phone, �gyLf Contractor's Nam � p;j�� License No. i32V Phan -S ln�" �i ZIA TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J ? PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ r' k�� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FDUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �( � LSU g INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Ola. of well Casing ❑ Public ❑Other ❑Delta Type of Casing I Li Irrigation Approx. ❑Eastern � Depth Specifications ❑Cathodic Protection Depth of Grout Seal �f ❑Geophysical G ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') s. i Depth Filler Material (Below 50') �•J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No e tic tank or seepage pit permitted if public sewer is C F '/ available within 200 feet.) r Installation will serve: Residence._ Commercial r Other Number of living units: Number of edrooms Lot size f Character of soil to a depth of 3 feet: iYl Water table depth f[o() f SEPTIC TANK Ei�Type/Mfg ( Capacity Na. Compartments z PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Dispospl SEWAGE SYSTEM Distance to:nearest: WellFoundation Property Line DESTRUCTION ❑ 1. �s LEACHING-LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS uI Depth Size �p ` Number SUMPS f Distance to nearest: Well ISO'; Foundation /Q� Property Eine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county t 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 E permit is issued, I shall not employ any person in such manner as to become subject to workman$ compensation laws of California." I{i �i^ii Contractor's hiring or sub-contracting signature certifies the following: '1 certify that in the performance of the work for which R tt this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applican u5t ca f all required inspections. Complete drawing qn reverse side. ISigned X - xQ Title: I11 Date OR P RTMENT USE ONLY ¢ ' � Appli ion Accepted by� Area �.� ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca7823-7104 Final Inspection by Date i �� y Tracy $35-63$5 Applicant - Return all copies to:. Environmental He th Permit/Services 1601 E. Hazelton Av P.O. Box 2009, Stk., CA 95201 FE£ BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO F1, L� - 10/82 500 (^, EH 13 24 REV. 82 E 1 0/ ` i4-26 i