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f4 - _ APPLICATION FOR oER,M,T f SAN .JOAQLi": LOCAL"'Hf,�L-TH DISTRICT �.� �-.1601 L- HAZE LIQ AVE., STCCKTON,' CF �. -. �•z, , Telephone.,(209)',4.66-6781'" +- PERMIT r a sr: PERMIT EXPIRES 1 YEAR�FROM DATA EEp, DATE ISSUED {Complete in Triplicate}. Application iii application made to s made Joaquin Local Health District for a pe'rzri'tTto construct and/or ins a1.1 the work herein described, This application is rade in compliance with San Joaquin'County Ordinance No.`549 for sewage or'No. 1862 for well/ um and.the Rules and Regulations oflthe San.Joaqu1n,Loca Health District. ; ..- ! Job Address p p �7 b-,E Subdivision Name A" " Owner's Name '4 , .._ �d s Contractor's Name ' }= 40-0Ar or / i r No. Phone �`� TYPE OF WELL/PUMP WORK: NEW WELL [ ELL REPLACEMENT DESTRUCTION ❑ ) PUMP INSTALLATION SYSTEM REPAIR LI OTHERk3 DISTANCE TO NEAREST: SEPTIC TANK _ U SEWER LINES /�) Tj OISP05AL FLQ. FOUNDATION PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA !J Industrial — CDNSTRUCTION SPECIFICATIONS en'Bottom CONST L^'Gmestic/Private Dia. of Well Excavation Public Gray.el. Pack Tracy Dia, of Well Casing � Other J ❑ Delta J'Irrigation A roxType of Casing Pp . Eastern� J Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal IC44 11%k J Other Type of Grout Repair Work Done Type of Pump1�.� H P Z State Work Done Surface Seal Installed by Wel] Destruction J} Well- Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION J (No septic tarok or seepage it p permitted if public sewer is Installation will serve: -1 _ Commercial Other available within 200 feet.) Number of livingunits: Number of bedrooms Lot size Character of soil to'a depth of 3 feet: 4 SEPTIC TANKWater table depth y Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. � Type/Mfg SEWAGE SYSTEM ----------- Capacity Method of Disposal DESTRUCTION E] Distance-to nearest: Well Foundation � Property Line � LEACHING LINE J No. & Length of lines FILTER BED Total length/size �- Distance to nearest: Well Foundation - Property Line SEEPAGE PITS ❑ Depth Size _ Number _ SUMPS L� DISPOSAL PONDS Distance to nearest: Well Line Foundation Property LiJ �c I hereby certify that I—have prepared this application and that the work will be done in accordance with San Joaquin county ordinance_s,.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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call fo l required in ections. Complete drawing on reverse side. Signed X ' ' � � Title: + Application Accepted by OR 0 P ME USE C1Y Date: 4QAArea J Stk - 466-6781 i Additional Comments: Pit or Grout Inspection Lrs Lodi 369-3621 Date Manteca 823-7104 Final Inspection by _ Date L7 Tracy 835-6385 Applicant - Return all copies to:. Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 a+. FEE BASE AMOUNT DUE AMOUNT REMITTEDRECEIVED 8Y d INFO y DATE PERMIT N0. a J /0 P7 y7- EH 14-26 REV, 10/82 4 / 7 2 500 J J