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� t J APPLICATION FOR PERMIT SGN JOAQJiN LOCAL HEALTH DISTRICT 1601 E. HAZLETON AVE., STOCKTON, CA PERMIT N0. � p Telephone (209) 466-6761 DATE ISSUED _ ¢ i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 Joaquir County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Ith D' Job Address uv45ian Name q q I - ;'Owner's Name Address 0 h4�23ic%Q 1 `� �f! � ref� � Phone Contractor's Name License No. r z TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER 1_I TO NEAREST: SEPTIC TANK pF SEWER LINES DISPOSAL FLO. PROP. LINE 4 - DISTANCE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I �'- — �`" CONSTRUCTION SPECIFICATIONS � INTENDED USE TYPE OF WELL PROBLEM AREA IJ Industrial ❑0 en Bottom ❑Manteca Dia. of Well Excavation j�omestic/Private Gravel Pack ❑Tracy Dia. of Well Casing Delta Y `'�`,I/ ❑:Public ❑Other` ❑ Type of Casing Irrigation - ' 'r Approx. ❑Eastern Specifications u' F. Depth ❑Cathodic Protection Depth of Grout Seal ❑Geophysical �. Type of Grout t ❑Other Surface Seal In by .EJ�a ✓ Repair Work Done ❑ Type of Pump P. ~State Work Done I ` Sealing Material (top 50') - f Well Destruction ❑ Well Diametir 9 - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ -".REPAIR/ADDITION ❑ (ND septic tank or seepage pit pirmitted ifpublic thin 200fsewer is avas ]nstallation will serve: Residence CommerciaI- Other Number of living units: R. 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 �- �. . .i ..-,a Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: lJell Foundation Property Line 4� DESTRUCTION I Total length/size- LEACHING LINE ❑ No. Zx'Length of lines : a 4f{ ❑ Distance to nearest: Well Fourdation Property Line FILTER BED e th� Size Number ,d SEEPAGE PDp ITS CJ. j•_ -� —� - �- --- "Property•_-•.K Foundation Property Line Distance to nearest: Well DISPOSAL PONDS ` ❑ I hereby certify that 1 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. work San Joaquin Local Health District. +for which this Home owner or licensed agent's signature cerfiffes-the following: "I certify that in the performance_of the permit is issued, T.shall not employ any person in such manner as to become subject to-workman� compensation laws'of California." in the perform Contractor's hiring or sub-contracting signature certifies the following: "I certify that performance of the work for which fornia." this permit is issued, I shall employ persons subject to workman's compensation laws of Cali ,. The applica must call fo r quired tiComplete dr i specons- w'ng on revers" side. nDate: - Signed X - ._Title. k DEPARTM T USE ONLY Stk 466-6781 Area Application Accepted by k ❑ Lodi 369-3621 Additional Comments: ffff ❑ Manteca 823-7104 Pit.,or Grout Inspection Date + _ Date f�kl # FJ Tracy 835-6385 Final Inspection by i,. , Applicant - Return all copieslio: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SL k., CA 95201 DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ]NFO 3 o-I�r - 3 � I 06, r 0182 00 f '*. ,EH 13-24 REV. 10/82 444 ,� X14-26