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} S APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO I 3 7&�)_S Telephone (209) 466-6781 DATE ISSUED (/ P PERMIT EXPIRES 1 YEAR FROM PATE ISSUED `7 (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 Re�juI tions of the San Joaquin Local Health District. I Jab Address 0t3s w I`n1 w Q Abdivision Name Owner's Name Address Phone Contractor's Name % on License No. 1 13 Phone TYPE OF WELL/PUMP WORK: NEWWELL ❑ WELL REPLACEMENT ❑ OESTRUCTION ❑ V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f FI Industrial _] OpenIBottom F-1Manteca Dia, of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of-Well Casing ❑ Public [j Other ❑ Delta Irrigation Type of Casing I L� g Approx. ❑Eastern I ❑ Specifications Cathodic Protection Oepth Depth of Grout Seal ❑Geophysical Other Type of Grout ❑ s �� _ -`� Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter## Sealing Material (top 50') _ Depth 1 Filler Material (Below 50') 0 L TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ REPAIR/,ADDITION (No septic•=tank..or.seepage pit-permit-ted if public.sewer ism available within 240 feet.) CSS Installation will serve: Residence Commercial Other 001 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet:' Water table depth ii SEPTIC TANK L] Type/Mfg i Capacity No. Compartments P PKG. TREATMENT PLT. ❑ Type/Mfg' Capacity Method of Disposal SEWAGE SYSTEMDistanceito nearest: Well Foundation Property Line DESTRUCTION C] 1 LEACHING LINE [ (f No. & Length of lines �� Total length/si.ze I FILTER BED, ❑ Distance�to nearest: Well Foundation Property Line k SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑ Distanceito 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 ( \1 f 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 workmanS 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 app lica. call W all r uired inspections. Complete drawing on reverse side. Signed X �1i1? Title: Date: 7- 29- 83 7 3 If FOR DEPARTMENT USE ONLY f Application Accepted by Area 6 - ❑ Stk 466-6781 1111 Additional Comments: A [] Lodi 369-3621 Pit or Grout Inspection by J Date .Manteca 823-7104 " j Final Inspection by l�� _ Date ( 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 �, ! � `-7o-L-S ` EH 13-24 REV, 10/82 10/82. 500 14-26 r