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_.. :- APPLICATION FOR.PER4,1T no UUSAN JOAQI'!N LOCAL HEALTH D15 E 1601 E. HAZELTON AVE., STOCKTON, CA � � Ny ��, ,p PERMIT NO. ✓ ��lJ r Telephone {209) 466-6781 - { Cha DATE ISSUED 1 PERMIT EXPIRES 1 YEAR FROM DATE 155 M JOAQU6N LOCAL i (Complete in Triplicate) _ HMTH DISTRICT "Application is hereby made to the "San�Joaquin Loci] Health District for a permit to construct and/or install the work herein i 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 iSan Joaquin Local Health District, Job Address Subdivision Name 41 Lo Address Phone �1/ ��d Owner's Name Phone Contractor's Name License No:. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' OA PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST-, SEPTI C.TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C 1NTENOED USE -TYPE--OF--WELL; PROBLEM-AREAY' c =�LONSTRUCTION SPE"CI"FItA710N5 Industrial ❑ open,Bottom ❑Manteca Dia. of Well Excavation DomestiWrivate F-1 Gravel Pack [f Tracy Dia. of Well Casing Public ❑Othep� ElDel to Type of Casing Lj irrigation Approx. ❑Eastern Specifications s. LD Cathodic Protection Depth. Depth of Grout Seal r ❑Geophysical Type of Grout ❑Other Surface Seal Installed by TypePump _ H.P. State Work Done P T1�4et Repair Work Done yP of I Well Destruction ❑ Well Diameter,f Sealing Material (top 50') Depth It Filler Material (Below 50') No septic tank or seepage pit permitted if public sewer is j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ( available within 200 feet.) installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size Water table depth W� Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK FIType/Mfg Capacity Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Property Line SEWAGE SYSTEM Distance to nearest: . Well Foundation P DESTRUCTION No. & Len th of lines Tota] length/size LEACHING LINE LJ g Property Line FILTER BED ❑ Distance to nearest: Well Foundation I Size.. Number Depth,, :r SEEPAGE PITS ❑ - _„�--•-.�.»• -w� � a..r+�-�•�-�"'.-,w� SUMPS F-1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS San Joaquin county I hereby certify that I have prepared this application and that the work will be done in accordance with 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 became 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 call for all required inspections. Complete drawing on reverse side. Date. 2 d � �Titlsigned X22 FOR E AR ONLY Area Stk 466-6781 Application Accepted by ❑ Lodi 369-3621 Additional Comments: Manteca 8237104 Pit or Grout Inspection by Date Final Inspection by �" Date�/f- ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health P mit/Services 1601 E. Hazelton Ave- P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT- DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. '( INFO p Ii_a_-Z3 �g�-iaaa f 4 10/$2.500 EH 13-24 REV. 10/82 14-26