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' APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (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 of the San Joaquin Local Health District. Job AddressT(�� J��(y/r%f code pp, Owner's Name f 17.Q14 &O Contractor's Name // /I/ j�Ti i`•License NdPhone TYPE OF WELL/PUMP WORK: g NEW WELL WELL REPLACEMENT DESTRUCTION❑ -PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK/OD SEWER LINES DISPOSAL FLD.� PROP. LINE 1QfT i. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE i', TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y _ 1-1 Industrial U Open Bottom_ nteca Dia. of Well Excavation /2?. y�omestic/Private - " " - i avel-Pack �7racy Dia".-'ofT4e17 Cas in§ �` "- '-'"'�` - - - �] Public Other Delta :•r ` + _ - <.. Type of Casing PIIC_` .L_]irrigation O Approx. Eastern Cathodic Protection Depth Specifications • $ Q 1 ❑Geophysical Depth of Grout Seal Pr l j�Other _..,_� TYP,T„of Grout ,4tl7B i A +Vim~ Surface Seal Installed by 1 1,--,--T Repair Work Done , Type of Pump H.P. State Work Done "I �• Well Destruction 1] Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') S i 1 TYPE OF SEPTIC WORK: NEW INSTALLATION (❑ REPAIR/ADDITION U (No septic tank or seepage pit pgrmitied if public sewer is '. " — availatile within 200 feet.) Installation will serve: Residence _ Commercial ti Other • j .� Number of living units: Number of bedrooms �_Lot size .F Character of soi.Lto_a_depthf ,.of_3eet: - Water table depth SEPTIC TANK Cj Type/Mfg Capacity .No. Compartments PKG. TREATMENT PLT. Type/Mfg 1 Capacity ^,.:Method of Disposal ,t /jam SEWAGE SYSTEM DESTRUCTIONi ❑ Distance to.nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance tonearest: Well Foundation ,,/ Property Line s� e SEEPAGE PITS G Depth j Size Number SUMPS U Distance to barest: Well Foundation: Property Line —DISPUSAL pow f "'"'.'.e:�-...�:r •..c+ ..•+:.-E ,r -ir.. )� I hereby certify that i have prepared this application and.tha—i4he wor4will be done in accordance with San Joaquin county f " ,+ ordinances, state laws, and rules andiregulations of the San*doaquin 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.shali not employ iiny person in such manner as to become subjeA,to workman§compensation laws of California." Contractor's hfFing p-r 5u&d6nfr:acting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,-I. Nll employ persons subject to workman's compensation laws of California." t ' The applica us ca for 1 required inspections. Complete drax Ig ori r erse •'.. Signed X � � Title: Date: . FO F TM I T USE O' ��Adpp e Appl icat ion_Acceptedby Area I _4FO Stk 466-6781 t ' Additional!Comments: Lodi 369-3621 \;r b Pit or Grout Inspection by ?;! Date Manteca 823-7104' _ Final Inspection'by? Tracy 835-6385 -\ , ' Applicant - Return'allcopies to Fi Enyironmental Health Permit/Services 1601 E.',Hazeltun Ave., P.O. Box 2009,-Stk.,�•CA 195201 FEE BASE .as AMOUNT ."DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. f' INFO "' y! ' EH 13-24 REV. 10/82 10/82 500 14-26