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�} APPLICATION FOR PERiV!T :T SAN JOAQLitf LOCA! iEPLT� CiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. L� � 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 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 forfwell/pump and the Rules and Regulations of the an Joaquin Loca Heal isttriljcta `, f Job Address 7 �""��1p �jf b { rf'N W+�(�( 9�E -per Owner's Name rQ /lf/� address a�P .LAl Phone Contractor's Name (J # S $ License No. Phone 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IE) Industrial U— Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public T-10ther ❑ Delta - Type of Casing . V Irrigation r Approx. E] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical U Type of Grout Other Surface Seal Installed by .-- ♦' Repair Work Done Type of Pump H.P. State Work Done Well Destructionlf Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION jJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other 44 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Q ` �. LEACHING LINE U No. & Length of lines Total length/size 1 FILTER BED Distance to nearest: Well Foundation Property Line E SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ f 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 a is nt�Imu t call for 11 r d an tion Complete drawing on�rjeverse sjde. Sign X / i 1 (�GZ/121/r� Date: ,D RTMENT USE ONLY Application Accepted by Area f!L 5tk 466-67$1 = Additional Comments: ® Lodi369-36 Pit or Grout Inspection b Date jj Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: Envi ental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVE BY DATE PERMIT NO. INFO � CD 3 w EH 113-24 4-26 REV. 10/82 /82 500 Q ` �/�/Z� l� I r✓t�-GYM„P7'/