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LIGATION FOR PERMIT. , JJ SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. l Y Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) rApplication 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 t San Joaquin Lo ai Health District. Job Address O Subdivision Name [Owner's Name Address L Contractor's Name � License No. Phone rTYPE OF '.FELL/PUtiP WORK: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca 1 ❑ Dia. of Well Excavation �J U Domestic/Private Gravel PackTrac Public ❑ y Dia. of Well Casing [j Other ❑Delta R—i Irrigation Approx. [J Eastern Type of Casing Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal F_J Other Type of Grout Surface Seal Installed by epair Work Done ❑ Type of Pump H.P. State Work Done it Destruction ❑ Well Diameter Seating Material '(top 501) p � Depth Filler Material (Below 501) V" O TYPE OF SEPTIC WORK: NEW INSTALLATION Ee+--REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if.public sewer is Installation will serve: Residence t.�_,Com erciai Other _ available within 200 feet.) Number of living units: A—. Number of bedrooms _ Lot size Character of soil to a depth ofy3 feet: Water table depth rSEPTIC TANK — Type/Mfg ". Capacity f T-w No. Compartments .PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Q Property Line DESTRUCTION Cl 1 LEACHING LINE L� No. & Length of lines 3 — Total length/size FILTER BED Distance to nearest: Well Foundation �� Property.Line �(> �EEPAGE PiTS Depth Size Number iSUMPS !J Distance to nearest: Well M FoundationProperty Line 'DISPOSAL PONOS 0 RIhereby 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. ome owner or licensed agent's signature certifies the following: "I certify that 'in the performance of the work for which this f 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-detracting signature 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." ,The applicant mu all fo a wired inspections. Complete drawing on reverse side_ Signed X Title: > (,(/i-• Date: ZO 17-�3 FOR DEPARTMENT USE iLY Application Accepted by L� d��)� j Q,� Area r�/ ❑ Stk 466-6781 Additional Comments: �"� Lodi 369-3621 Pit or Grout Inspection by e7 Date ❑ Manteca 823-7104 PApplicant Final Inspection by� Date"��e 3 ❑ Tracy 835-6385 - Return all copiel`t'o:. Environmental alth Permit/Services.,1Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO Lay EN_i 344 REV •10/82' r �'• _ t:- _". . 10/82 500 }