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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT C 1601. E. HAZELTCN AVE,, STOCKTON, CA PERMIT NO. Telephone",(209) 466-6781 A., DATE ISSUED 3 PERMIT EYPIRES '1 YEAR FROM DATE ISSUED- (Complete in Triplicate) I Application is hereby made to the San Joaquin Loca).-Health District for a permit to construct and/or install the work herein i 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 oo�f^^ the San Joapuin Local Health District, Job Address 410A J 1 Subdivision Name } Owner's Name�8 .,.,prI 1 q f Address a cx6o YV Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT$/SUMPS INTENDED USE '-"TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial LJ Open Bottom Manteca Dia. of Well Excavation [� U Domestic/Private Gravel-Pack ❑Tracy`s' Dia, of Well Casing V ` Pubi is Other - Delta Irrigation. Approx. Q Eastern Type of Casing , Cathodic Protection Depth Specifications Geophysical , + Depth of Grout Seal LJ Other Type of Grout Surface Seal Installed by Repair Work Done L Type of Pump H.P. State Work Done J Well Destruction U Well Diameter Sealing Material (top 501) PDepth Filler Material (Below 50') TYPE OF SEPTIC'WORK: NEW41NSTALLATION ` REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is 0 Installation will, serve: available- Residence � Commercial _ Other ,within 200 feet.) Number of living units:' l Number of'bedrooms _ Lot size /G, ''11-L G Character of soil to a'de th of 3 feet:P sif�/'`fC} - Water table depth SEPTIC TANK 2 Type/Mfg Capacity Q y" r - �_ No. Compartments �- —� PKG. TREATMENT PLT. ❑ :..Type/Mfg Capacity Method of Disposal S i SEWAGE SYSTEM ❑ Distance to nearest: Well DESTRUCTION ` Foundation /O' Property LineQ,� S' LEACHING LINE U No. .& Length of lines D Total length/size 3 0 31`, 5 FILTER BED Lel Distance tohnearest: Well L5� Foundation 10 Property Line G i E SEEPAGE PITS LI Depth Size Number 4 SUMPS Distance to nearest: - Well Foundation Property Line DISPOSAL PONDS L 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. p, 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 appl " t s call for all q r inspe ans. Complete dr ing or reverse side. _ Signed X Title: �(�Jl]r�/l— Date: -5— Application rt � DEP NT USE Application Accepted by 3 [� Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by -Date S >f 3�� la' L Tracy 835-6385 t Applicant - Return all copies Environmental'Health Permit/Services 1601 F. Hazeltor Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT,NO. INFO EH 13-24 REV. 10/82 l /` Q� 10/.82 500 14-26 CA_I �13 1