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G I� k I APPLICATION FOR'PERMIT SAN JOAQUIN,LOCAL HEALTH-DISTRICT 1601 E. HAZELTON AVE., STOCKTON, T NO. p ✓f '� Telephone-(209) 466-6781 N Q v � A i DATE ISSUED -�3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PLL (Complete"in Triplicate) SAN ioAQUIN LOCAL Application is hereby made to the San Joaquin Local Health District for permit a c �fQ1all 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 othe San Joa 'n local Health District. i Job Address G , .P. Subdivision Name Owner's Name !/�� iiAddress . Phone --7 Contractor's Name I e3n a 1 License No. ; Phone WA !9,nml TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 1 _ PUMP INSTALLATION SYSTEM REPAIR ER I El OTHER u,_ DISTANCE TO NEAREST: SEPTIC TANK �� SEWLINES DISPOSAL FLO, PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ In strial Open Bottom ❑Manteca Dia. of Well Excavation mestic/Private F-1GravelPack ❑ Tracy Dia. of Well Casing t 1-1 Public F-1 Other Delta Type of Casing U Irrigation 4 Approx. [] Eastern ` Depth Specifications ❑Cathodic Protection ti Depth of Grout Seal 1-1 Geophysical Type of Grout Other i Surface Seal In lled by Repair Work Dane Type of Pump H.P. State Work Done Well Destruction ElWell "Diameter Sealing Material (top 50'). I Dept4 Filler Material (Below 50') h i TYPE OF SEPTIC WORK: NEW;INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) E Installation will serve:. Residence _ Commercial _ Other Number of living units:I� Number of bedrooms : 4 Lot-:size Character of soil to a depth of 3 feet: Water table depth'' _ SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I�Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE J�No. & Length of lines Total length/size FILTER BED F-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS F-1 Depth Size Number SUMPS LJ 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: "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 must for all r ed insp t' ns. ete d r v se s'd Signed X45"� f ,, •Ir, .,�.� _.- - rt � '---FOR DME NL' 4 Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3521 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental He h Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA - 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO $3-1a7 EH 13-24 REV. 10/82 � 10/82 500 y I4-26 S --