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APPLICATION FOR PERMIT , rt SAN JOAQUIN LOCAL HEALTH DISTRICT a nn ' 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. o2— E # Telephone (209) 466-6781 — ;s DATE ISSUED, 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_��z St uSubdivision Name Owner's Name I� _ Address 1L-4&JAJy AU-1 Phone 4 _�74/7 Contractor's Name License No. 44A Phone __l7/R. TYPE OF WELL/PUMP WORK: NEW. WELL Q WELL REPLACEM€NT DESTRDCTION ` PUMP. !NSTALLATION 0 SYSTEM REPAIR OTHER [] 1 � DISTANCE TO NEAREST: SEPTIC TANK I: SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS I INTENDED USE TYPE 'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 17 Industrial0 Bottom LJ en P � E]Manteca Dia. of Well Excavation � Domestic/Private E] Gravel Pack Tracy Dia. of Well Casing L� Public [j Other Delta Type of Casing U Irrigation Approx. Eastern ❑Cathodic Protection Depth = Specifications Ej Geophysical c ; •, Depth of Grout Seal U Other , Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction Lf Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/AODITION '� (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence X Commercial Other available within 200 feet.) i Number of living units: -_ Number of bedrooms . � ; Lot sizeQ Character of soil to a depth of'3 feet: j Water table depth SEPTIC TANK Type/Mfg 4a' r. p Capacity _'f Cj `o. Compartments PKG. TREATMENT PLT. Type/Mfg + Capacity Method of Disposal �~ f Distance to nearest: Well Foundation _A=t Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED E] 410 nearest: Well Foundation Property Line SEEPAGE PITS Depth s / Size 33 Number _ SUMPS L1 Distanc "�to nearest:' Well Foundation ! Property Line /® I, DISPOSAL PONDS E) ii 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'bf 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 hi ing or sub-contract" g signature certifies the following: "I certify that in the performance of the work for which this permit is ssued, I shall em o persons subject to k Y P workman's compensation Taws of California. The applic call for a equiP�d inspections. Compl to on reverse side. Signed X Title: Date.• 1� F R DEPARTMENT USE ONLY Application Accepted by Area >j— Stk 466-6781 Additional Comments: 6,7 Ej Lodi 369-362.1 Pit or Grout Inspection by _ Date � �� ❑ Manteca 823-7104 Final Inspection by '. 0M Date 16 _ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Serv,ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT N0. � quo lEa-�� y EH 13-24 REV. 10/82 10/82 500 14-26