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r APPLICATION FOR PERMIT r �~ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.� Telephone (209) 466-6781 ; DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby rade 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. 544 for sewage or No. 1862 for well/pump and the Rules and/ Re ulations of� �the San Joaquin Local Health District. y' / Job Address / 6, 3 ,� S-, (di 12 r A&C- ead e t Owner's Name _T Address _;7li 1-11 �e} c_. Phone Contractor's Name rr ,,LL7cense No. 23. ? _� � ___„_ Phone ft�J�Z k ISS TYPE OF WELL/PUMP _WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION v PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ 7 ! DISTANCE TO NEAREST: SEPTIC TANK �y ( SEWER LINES <0 �4 DISPOSAL FLO./ fff_A_ PROP. LINE FOUNDATION AGRICULTURE WELL 1-4 _ OTHER WELT _- PITS/SUMPS 1 INTENDED USE TYPE OF WELL FI Industrial ❑ Open Bottom Domestic/Private ryGravel Pack 'J Public ❑{Other jirrigation 44�0Approx. ❑ Cathodic Protection Depth (� Geophysical Other Repair 'Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Depth PROBLEM ARjA CONSTRUCTION SPECIFICAT10% rr Mame Dia, of Well Excavation Tra Dia. of Well Casing iJ to Type of Casing _ 1,q AS Dltastern Specifications = V d Depth of Grout Seal _ '�!J t Type of Grout M £k L#�- Surface Seal Installed by — 31. P. State Work Done — Sealing Material (top 50') Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage. pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK E-1 Type/Mfg u PKG. TREATMENT PLT. ❑ Type/Mfg Septic Tank d Distance to nearest: Well Destruction --- Other Lot size _ Water table depth M Capacity _y No. Compartments Capacity — Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS [^i Depth Size Number SUMPS ED Distance to nearest: Well Y ^ Foundation _ Property Line DISPOSAL PONDS ❑ 1 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 enploy any person in such manner as to become subject to workman compensation laws of California,” Contractor's hiring or sub -contracting si nature certifies the following: "I certify that in the performance of the work for which this µerrnit is issueJ;11allploy ons subject to workman's compensation laws of California," The applicant st creq ections. Complete drawing on r verse side. 1 Signed X__ Title: Date: FOR CEPARTMENT USE ONLY Application Accepted by �' Area_ _� _ ❑ Stk 466-6781 Additional Comments;— qj ❑ Lodi 369-3621 Pit or Grout Inspection by L Date ~ 1 � -'� i� ❑) Manteca 823-7104 Final Inspection by \� _ Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Ile th 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 EH 13-24 REV. 10/82 10/82 500 14-26