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,yam ��'t 1 YYl g APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZFLTON AVE.,�STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ` DATE ISSUEO 44`7-0— 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete,in Triplicate) Application is hereby made to the San Joaquin Local Health District for d 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 Regulation.5sof. the San Joaquin Local Health District. Sob Address -� _ Subdivision Name Owner's1'Name r.— Address Phone 5 Contractor's Name- {� � License Na. Phone TYPE OF WELL/PUMP WORK: NEW WELL �WELL,.R£PLACEMENT ❑" " ..DESTRUCT ION ❑ �p PUMP INSTALLATION ❑ SYSTEM''REPAIR- ❑ s if OTHER ❑ v DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL_D. PROP. LINE FOUNDRTION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 17 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Oomestic/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 LJ Other - - h --- Surface Seal Installed by Repair Work Done [J Type of Pump: H.P. x State Work Done J Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 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.) I Installation will serve: Residence X. Commerci— _ Other i/ , ` Number of I ivi.ng units: - Number of bedrooms Lot size ] r'?l�n�� `-rV� Character of soil to a depth of 3 feet: Water table depth S SEPTIC 'TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity � Met�,hod of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation p rtylLine N,DESTRUCTION 1 LEACHING LINE No. & Length of lines Notal length size FILTER .BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth a Size f1 Number "a SUMPS �� Distance to nearest: Welllundation Property Line .i DISPOSAL PONDS ❑ i 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, f* which Home o%iner-or licensed agent's signature certifies the following: "I certify that in the performance of the work for this permit-,is issued, I shall not employ any person in such manner as to become subject to workman t compensation.,laws of California." CoQtractor'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 sh rl�l employ persons sub' to workman's compensation laws of California." f � , The applic�nt�musoc,, for 11 ne uir d. inspe ion Complete dr ing on'rev Signe e� 1` 1 itle: � Date: r . ,, ... ' T U ONLY `�� Application Accepted by - 6 -- Stk 466-6781 Lodi 369-3621 'Additional Comments: Date y~ ❑ Pit or Grout Inspectio y _ Manteca 823-7104' Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO., NFO { 10/82 500 EH 13 124 REV. 10/82 r l 14'26 J