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APPLICATION FOR PERM17 SAN JOAQUiN LOCAL HEALTH DISTRICT ��` 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 4664781 /1 _s�10—�� r PERMIT EXPIRES 1 YEAR FROM GATE ISSUED DATE ISSUED /V (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 s 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 n Re ulation f the San Joaquin Local alth District. /' Job Address Subdivision Name ANYY'e71/ Acgyx 4?_,W C1d14V Owner's Name Address Phone r Contractor's Name icense No. 3 7? Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE pJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I] Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation - ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing S ❑ Public ❑j Other ❑ Delta TY ee of Casing Irrigation Appx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout r ❑Other Surface Seal Installed by Repair Work Done r] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) r Depth Filler Material (Below 50') -� TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) y, Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments - r PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ .. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE [J— Depth � Size Number .. SUMPS l� 7� Distance to nearest: Well Foundation Property Line 10vee DISPOSAL PONDS ❑ I hereby 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. 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� 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 em I persons subject to workman's compensation laws of California." ` Thea licant t 11 r all L pp q fired in spectio plate drawing on re//verse side. �7-� -- Signed X le: CDYI�'(�l.T/f7� Date: lQ-26 ^FQQ88 PA M USE ONLY r Application Accepted by � �JiLGc.�-- Area -�_ � Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b _ Date ❑ Manteca 823-7104 Final Inspection by C, Date ❑ Tracy 835-6385 r Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 r