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APPLICATION FOR,PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT ISSUED N0. �• Telephone (209) 466-6781 .,, DATE 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 R do s of he San Joaquin Loca H lth District. Job Address , Subdivision Name Owner's Na Address r Phone s Contractor's Na , ' "Z G! License No. � Phone TYPE OF WELL/PUMP WORK: NEW WELDQ . of ❑.s - ' WELL_REPLACEMENT **+DESTRUCTION U � ''PUMP 144STTALLATION SYSTEM"REPAIR — "" OTHER, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE$'• DISPOSAL FLO. PROP. LINE FOUNDATIbN + AGRICULTURE•FIELLti OTHER WELL PITS/SUMPS .- INTENDED USE TY?EIOF WELL PROBLEA REA C 4ONSTRUCTION SPECIFICATIONS i S 1-1 Industrial U Open Bottom �]Manteca Dia, of Well Excavation C Domestic/Private ' L.J �Gravel Pack � TraCy ,Dia, of-Well Caking • L] Public El Other [ ,Del to ' Type of Casing i-iirrigation Approx. '[Eastern S ; ❑ Cathodic Protection Depth ;e;4 Specifications Geophysical •Depth of Gro'Ut.Seal i t �.. Other f + TYpe al Groin i surface SW' Installed by Repair Work Done ❑ Type of .Pump "'.. H.P. State Work Done r « Well Destruction (] We,11'iDi.ameter + ^ `'ASealing Material (tdp 5D'j• r Depthtr�! Filler Material-(Below50') TYPE OF SEPTIC WORK: NEW INSTALLATION" REPAIR/ADOITION -+ N ( o-septic tank or seepage pit permitted if public sewer is av;ilabi&within 200 feet.) Installation will serve: . Residence _ Comercial A10 Other Number of living units: Number of dro ms "`+ '" Lot size ;J �.. �1 . r Character of soil to a pth of 3 eet: ater table depth SEPTIC TANK Type/Mfg 6 e' Capacity o. Compartments _ PKG. TREATMENT PLT. Type/Mfg = '� "" '" "Capacity Method of Disposayl SEWAGE SYSTEM Distance to nearest: Well r Foundation Property Line ' DESTRUCTION ❑ LEACHING LINE U No. & Length�of lines Total length/size11 r FILTER BED Distance to nearest:.,.Well Foundation Property Line SEEPAGE PITS [j Depth ' A Size .- Number SUMPS U Distance to nearest: _%ell 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.fol lowing.."I certify that in the performance of the work for.which this permit is issued, I shall not employ any person in such mariner as to become subject to workman§compensation laws 'of California." Contractor's hiring or sub-contracting signature certifies tne: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 m t ca 1 f dl equire�ins ections. Complete drawing on e r e side. nn Signed X ' Title: V 0,1 Date: IV OR �PARNT ONLY �.. N , - • Application Accepted by Area ..�P_Stk._r 466-6781 Additional Comments:, > Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by C) Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 160 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 " 10/82 500 14-26 M 1