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APPLICATION FOR PERMIT FTPERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT1601 E. HAZELTON AVE., STOCKTON, CA �/ \'! NO. $ll-1L1S Telephone (209) 466-6781 DATE ISSUED Li PERMIT EXPIRES 1 YEAR FROM 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 Address � �i 4 'r C MSFyZ - RD Subdivision Name Owner's Name rlcl PA2*G/Sf Address AA 6"6_4' Phone Contractor's Name 4 (�� License No. Phone „23 IJ/23 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well-Casing ❑Public ❑0ther ❑ 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. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION EJREPAIR/.ADDITIY�/ON � (No septic tank or seepage prtra ava i lableewithinu200cfeete) is Installation will serve: Residence _ Commercial Other Number of living units: .Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK f_1Type/Mfg Capacity PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line C DESTRUCTION No. & Length of lines /h Yet 2 �t 7 X 10 Total length/size _ LEACHING LINE U g �� FT Property Line FILTER BED � Distance to nearest: Well >/��= Foundation �_ Y Size Number SEEPAGE PITS ❑ Depth Property Line SUMPS ❑ Distance to nearest: Well Foundation 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 workmah compensation laws of California." t 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 applicant �mmuust ca f 11 rq ired inspections. Complete drawing on reverse side. Date: Signed X e* roc J�� Title: ee jj� FOR DEPARTMENT USE ONLY Area r ❑ Stk 466-6781 Application Accepted by — _! ❑ Lodi 369-3621 Additional Comments: 1 anteca 823-7104 Pit or Grout Inspectio by Date Final Inspection by. i rliy"�� Date TBox 9, St1k85 Applicant - Return all copies od Envi oirme6jar Aealth Permit/Services 16 Ha el n Ave., P.O. Box 2009, Stk., LA 95201 ri EFO DUE AMOUNT REMITTEDRECEIVED BYATE PERMIT N0. J - 10/82 500 EH 13-24 REV. 10/82 V 14-26