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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AYE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a perynit 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. -TV'-4%bdi vision Name Job Address /:?OZI V / JAL_ P&V gj Phone Owner's Name 0,,d_ Address Bv�� Contractor's Name r._Ucense No. 3 Tlel-3 Phone �---FL-ncep-nwillm OF..... TYPE OF WELL/PUMP WORK: NEW WELL F-1 WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER [J- 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 [J- Open Bottom []Manteca Dia. of Well Excavation Domestic/Private F-1 Gravel Pack F—� Tracy Dia. of Well Casing 0 Public r-10ther El Delta Type of Casing X Irrigation Approx. E] Eastern Specifications E] Cathodic Protection Depth Depth of Grout Seal 0 Geophysical Type of Grout 1-71 Other Surface Seal Installed by Type of Pump Sit& H,P. State Work Done 01A*t fflk rr,9� ch, Repair Work Done El 5-- 9 Well Destruction [J- Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION F—� REPAIR/ADDITION Cj- (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve. Residence Commercial Other Number of living units: Ntimber of bedrooms Lot size Character of soil to a depth of 3 feet; Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. Type/Mfg Capacity SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Wel I Foundation Property Line SEEPAGE PITS Depth _ Size Number SUMPS Distance to nearest: Well Foundation Property Line 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: ,, C ertify that in the performance of the work for which this permit is issued, s employ persons subject to workman's compensation laws of California." The applican ust ca�1 or I required inspections. Complete drawing on reverse side. Date: signed X 9�a 0.-.-e - Title: cg=s i'd a, W $OR DEPA MENT U o Stk 466-6781 Application Accepted by Area Additional Comments: N Pit or Grout Inspection by Date aaL '11 ion by Date 835-6385' Final 'Inspection by Service, p. Box 2009, Stk., CA 952 En r nmental�Realth Permit/Services 1601 E. Hazelton Av/. 4 Applicant - Return all copies to: A TE PERMIT NO. FEE �. BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DA' Tir, [INFO Ek 13-24 REV. 10/82 10/82 500 14-26