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APPLICATION FOR PERMIT SAN JOAQbi1,' LOCAL ;17AL1H DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 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 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 San Joaquin Local Health District. Job Address /X000 'S�• A14'- 9F—AArf le"% Subdivision Name Owner's Name 0-eh ,A 1/I-k cif a/yet Address Se ho44-y `t .K J1 feb' Phone 5$]_- 0 G 7 Contractor's Name Sr.m.q 7 License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ,�Y PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation V ❑ Domestic/Private ❑ Gravel Pack [] Tracy Dia. of Well Casing 1] Public ❑Other ❑ Delta Type of Casing Lj Irrigation Approx. Eastern F-1CathodicProtection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') C>0 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial A-.--otherr A Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK .:Type/Mfg Capacity /TOO No. Compartments Z PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE Safi No. & Length of lines3 ~/0U 01 Total length/size goo )Cx FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line 44 DISPOSAL PONOS Q 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 workmant 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 apf_pl-icant must call for a required inspections. Complete rawing ou reverse side. Signed X Title: +s Date: ART T USE ONLY Application Acce ted y Are [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 Final Inspection by Date �3 ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. LA EH 13-24 REV. 10/82 P�Ca 10/82 500 14-26 1 !�`