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lr APPLICATION FOR PERMIT SAN JOAQUF" LOCAL HEALTH DISTRICT ��(( 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. v T� Telephone (204) 466-6781 DATE ISSUED 12 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Appllcation 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 Regulation of t(h) SanJcaquin.Local Health District. Job Address ` V W.1 Q rJ— Subdivision Name Owner-'s Name' + Address Phone z. Contractor's Name: 4 1EX, �` cense No. S5 I Q Zi Phone TYPE OF WELL/PUMP WORK: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION ❑ /: SYSTEM REPAIROTHER * ❑ U DISTANCE TO NEAREST: SEPTIC TANK a SEW£R'LINES=,- DISPOSAL FLD. PROP. LINE {- -.... -- �-.�.:..,.�. FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS ? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ❑,Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well CasingY �_ ❑ Public ❑ 0thr^ E] Delta Type of Casing 't F"Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump 0 H.P. State Work Done Well Destruction ❑ Well 'Diameter-*'. Sealing Material (top 50') t Depth �'—Fi9'l.er'Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATIONL� REPAIR/ADDITION ot (No septic tank or seepage pit permitted if public sewer is s I available within 200 feet.) V) n it serve: R s"dence Commercial Other F Installation will 5 - 7 Number of living units: Numbber f bedrooms " Lot size Character of soil to.a�depth-of,3 feet: ��11A C Water table depth SEPTIC TANK ❑ Type/Mfg "" `Capacity < No. Compartments Ca acit Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg p Y p SEWAGE SYSTEM Distance to nearest: Weil Foundation Property Line , t r r DESTRUCTION i LEACHING LINE ❑ No. & Length of lines , fr V TotAla"ength/size----� — FILTER RED ❑r Distance to nearest: Well Foundation Property Line Depth SzeNumber PITS / SUMPS Distanc'e`to nearest: Well Foundation Property Line ; DFSPDSAL PONOS ,Ll GU "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 issu d, I shall employ persons subject to workman's compensation laws of California." Thea p I st ca 1 r al req red i s.pections. Complete dr n n re erse Sign Title: Date: F RTMENT USE ONLY S Area l - ❑ 5tk 466-6781 { Application Accepted by' r . , Additional Comments: ❑ Lodi 369-3621 ` Pit or Grout Inspection byl Date '� Manteca 823-7104 F i f � Final Inspection by Date � _ 9� ❑ Tracy $35-6385 Applicant - Return all copies t Environmental Health Permit/Services 1601 E, Hazelton A ., P.D. Box 2009, St k., CR 95201 EI ' FEE BASE "AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 560 J14-26