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APPLICATION FOR PERM;T r ' SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 e PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 AMOUNT DUE described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump SEEPAGE P'F,l'S,•`- Depth moi; Size 33 �i Number ( w and the Rules and Regulations of the San Joaquin Local Health District. �Q�lf g Job Address ^.% ab Subdivision Name �jf`/S%�sajj of Owner's Name Rif S 7, ZZE S S Address �2rs E � Phone — Contractor's Name r , ZZ/d4D License No. �.7G Phone_r g �� Herne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION G G PUMP INSTALLATION SYSTEM REPAIR OTHER 0 S DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T US INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial U Open Bottom [] Manteca Dia. of Well Excavation Pit or Grout Inspection by Date / J — Z4/ 7 V L-] Manteca 823-7104 LJ Domestic/Private Gravel Pack ❑ Tracy Dia. of -Well -Casing . 17 Public D Other [] Delta Type of Casing Irrigation L_i 9 Approx. ❑ Eastern Specifications Cathodic Protection Depth Depth of Grout Seat Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction F-1 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') of , 2M TYPE OF SEPTIC WORK: NEW INSTALLATION L� REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is J available within 200 feet.) Installation will serve: Residence Commercial Other _✓ Number of living units: r✓ Number of bedrooms 3 Lot size /g ArxE s nt/L q ! Character of soil to a depth of 3 feet: Water table depth {' SEPTIC TANK [j Type/Mfg ae- - - Capacity No. Compartments PKG. TREATMENT PLT. [J Type/Mfg +�; Capacity Method of Disposal (� SEWAGE SYSTEM tt---11 "ce �"near6st:-* WEI""* Foundation Property Line DESTRUCTION u d� LEACHING LINE & Length of lines Total length/size Mance AMOUNT DUE FILTER BED ,. to Aearelt: Well Foundation s Property Line PERMIT NO. SEEPAGE P'F,l'S,•`- Depth moi; Size 33 �i Number ( w ti SINi.PS� F L) Distance to nearest: Well _OLfo Foundation %yf Property Line .2_*4V g 4 b1 sk%AL 00009t,, ",C1 � I hereby certify that,I have prepared this application and that the work will be done in accordance with San Joaquin county Local Health District. ordinances, state la*,.andarules and regulations of the San Joaquin Herne 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 applicant must cal for a l required ins ctions. Complete drawing on reverse side. Signed X ` Title f%_ t- Date: T US Application Accepted y Area 9— ,�Stk 6-6781 Additional Comments- [) Lodi 369-3621 Pit or Grout Inspection by Date / J — Z4/ 7 V L-] Manteca 823-7104 Final Inspection by Date IV- 25/-p3 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. INFO 11 S .I z ar3 g EH 13-24 REV. 10/82 14-26 V 10/82 500