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APPLICATION FOR PERMIT i SAN JOAQUiN LOCAL HEALTH DiSTRICT �O i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � Telephone (209) 466-6781 DATE ISSUED 70��F PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 4 (Complete in Triplicate) Application i's-hereby rade 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_ '� _ �.[�'/LI�, A Subdivision Name Owner's Name L Address ./ Z Z Z 1"OA /-7 t10 C71 Phone �47,i a/SZ Contractor's Name mL" ?44License No. Phone p� TYPE OF WELL/PUMP WORK: NE4 WELL r7 WELL REPLACEMENT DESTRUCTION w PUMP INSTALLATION ❑ SYSTEM REPAIR LFI OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE'4 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom 0 Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel Pack E]Tracy Dia. of Well Casing L] Public [—I Other Delta Irrigation Type of Casing LI g Approx. as Cathodic Protection Depth ` Specifications Depth of Grout seal ` ❑Geophysical h LJ Other Type of Grout Surface Seal Installed by �Y Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top SO') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 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 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line DESTRUCTION i LEACHING LINE U No. & Length of lines Total length/size E FILTER BED Distance: to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth It Size Number SUMPS L1 Distance� to 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's sigp ature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall riot 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 for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FO DEPARTMENT 0 ONLY Application Accepted by C ,_AY(-- Area — /� f Stk 466-6781 Additional Comments: --- �' Lodi 369-3621 Pit or Grout Inspection by i Date ❑ Manteca 823-7104 Final Inspection by Date LI Tracy B35-6385 Applicant - Return all copies to:.. En elronmental health Permit/Services .1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT 0UE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i d EH 13-24 REV. 10/82 10/82 500 14-26