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r APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ��_l o PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED -`rs3 (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 Regulations of the San Joaquin Local Health District. W Jab Address °��%�nd� �, �J� �� Subdivision Nameq /rQ� __ t Owner's Name, p'�44 Address 'a,%3kLc_-4S V\. �bPhone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION 03 PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK ��` SEWER LINES DISPOSAL FLD. PROP. LINE Ac FOUNDATIONQ r AGRICULTURE WELL OTHER WELL PITS/SUMPS Z�" gsf INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial �Dpen Bottom Manteca Dia. of Well Excavation \_t.�, E.-f<mestic/Private Q Gravel -Pack Q Tracy _ _ Dia.. of.Well. Casing 17 Public Other Delta Type of Casing ❑ Irrigation 77 Sg:( Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done El Type of Pump H.P. �� State Work Done Well Destruction U Well Diameter Sealing Material (top 501) 00, C�Q��, � GIN Depth Filler Material (Below 50') � O}� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is '�1 available within 200 feet.) Installation will serve: Residence _ Commercial Other 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 DESIRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS 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 applic�aanntmust call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by t f Area 6�__ Stk 466-6781 Additional Comments: 4 Lodi 369-3621 Pit or Grout Inspection by ` Date Manteca 823-7104 Final Inspection by qAluff Date L7Tracy 835-6385 Applicant - Return all copies o. Enviro a tal Health Permit/Services 1601 P� Hlel Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO x15 00 - 0� 3 s3-\ztn3 EH 13-24 REV. 10/82 — - 10/82 500 14-26 7 moi-!