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V APPLICATION FOR PERMIT SAN JOAQLi`: LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. O ff Telephone (209) 466-6781 } DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , i (Complete in Triplicate) t 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 Reg lotions of t San Joaquin Local Health District. Job Address A &40-- Y )Subdivision Name f7 Owner's Name .-/ Address /f S Phone Contractor's Name License No. Phone � / Acff11 i TYPE OF WELL/PUMP WORK: NEYl WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL LD. PROP. LINE G FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation i P ,pomestic/Private ❑Gravel Pack F-1TracyDia. of Well Casing EI,Public C1 Other ❑Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout {�Other Surface Seal Installed by { Repair Work Done Type of Pump H.P. l 2 __ State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 sewr TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage p'evailableewithinubl200cfeete) is I Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size j Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK [—I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F_ . Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM C3 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED ❑ Distance to, nearest: Well Foundation Property Line i SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI I hereby certify that 1 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!s 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 to workman's compensation laws of California." The applican ust call f all required inspections. Complete dr wing on re erxl / w Title: Date: Signed X �! ��vL.�� •. FOP,,PEPARTMENT USE ONLY 466-67$1 �q Application Accepted by 4. Area Stk- Z� ❑ 9 6`5 W Lodi 369-3621 Additional Comments: p Manteca 823-7104 Pit or Grout Inspectio�,, b�- , Date Final Inspection by Date L7❑ Tracy 835-6385 �(J' Applicant - Return all copie5201 s ronmenta Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 � i PERMIT NO. [FEFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ry� J 10/82 500 EH 13-24 REV. 10/82 3 I4-26