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APPLICATION FOR PERM;T SAN JOAQUiti LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, LA PERMIT NO. o J 2 Telephone (209) 466-6781 DATE ISSUED IISa-7-3 PERMIT 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 Ordinan a No. 549 for sewage or No. 18fi2 for well/pump and the Rules and Regulatios of the San Joaquin Local Health District. Job Address Subdivision Name Address r'g®47 Owner's Name W Phone License No. 3 Contractor's Name _ I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE W 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 ❑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. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') -- Depth Filler Material (Be w 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ ON (No septic tank or seepage piavailablet itted thi if public fsewe) i911T, s o Installation will serve: Residence 4 Comme ial Other Number of living units: Number of bed ms _ Lot size �C Character of soil to a depth of 3 feet: ` Water table depth j4,, v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments —T PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION C] LEACHING LINE No. 8 Length of lines b Total length/size d2 Zb FILTER BED ❑ ,listance to nearest: Well � undation Lo J,4�Property Line --f—_ SEEPAGE PITS Depth .� Size " Number I SUMPS ❑ Distance to nearest: Well (-f747_/ Foundation ' Property Line Jr 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 iss I shall employ per ns subject to workman's compensation laws of California." The applicant call for all re spactions' Complete drawing on reverse side. Signed % Title: r Date: /� B FO DEPARTMENT USE ON Stk 466-6781 Application Accepted by Area rO ❑ Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 / =y—� Final Inspection by Date, ❑ Tracy 835-6385 Applicant - Return all copie to. Envir nmental Health Permit/Services 1601 E. Hat elton Ave., P.O. Box 2009, Stk., LA 95201 rFE I BASE AMOUNT OUE AMOUNT REMITTED RECEIVED BY DATE p ? PERMIITnNO.O 1U—r28—/.J 3-�2-bJ 10/82 500 EH 13-24 REV. 10/82 14-26