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7. 17 Ud fn` APPLICATION FOR.PERMIT i i SAN JOAQUiN LOCAL HEALTHF .pISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO.' Telephone (209) 466-6781. DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6... . (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` o. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatio s.of th an Joaquin Local Health District. Job Address & �" 3�_� Subdivision Name Owner's Name �G 5 Address- F-1 L 'Ree ' Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WFLL REPLACEMENT DESTRUCTION : PUMP.INSTALLATIONSTEM REPAIR OTHER W W. DISTANCE TO NEAREST: SEPTIC TANK +ti �, . SEWER LINES DISPOSAL FLD. PROP. LINE 1 l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF'kd7- PROBLEM AREA CONSTRUCTION SPECIFICATIONS Fj Industrial U Open Bottom Manteca" Dia. of Well Excavation g-Iro-.estic/Private ¢ [j4-Gr,Tvel Pack 0 Tracy Dia. of Well Casing G� Public Other Delta x Type of Casing V irrigation pprox. Eastern Specifications _. �(j• �__.__ Cathodic Protection Depth - r• �• k " �,� Depth of Grout Seal Geophysical ` E6 Type of Grout �c,c�n..� Other Surface Seal Installed by Repair Work Done ❑ Type ofdPump HSP, —"3State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth # Filler Material (Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ,F-I N(No septic 'tank or seepage pit permitted if public sewer is available within 200 feet.) lnstaliation will serve:- Residence _ Commercial Other Number of living units: Number of bedrooms Lot sitze Y Character of soil to a 'depth of.3 feet:• Water table depth SEPTIC TANK �� Type/Mfg Capacity No. Compartments I PKG. TREATM(NT''PLT-Q'Type/Mfg j _ Capacity Method of Disposal SEWAGE SYSTEM Aistance to nearest: Well Foundation Property.Line k DESTRUCTION LEACHING LINE LI No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS U 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. x .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 t 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 per ons subject to workman's compensation /laWSrof California." The applst call for a equire inspect" s. Complete drawing on reveride. Gf Signed X it1e: Date: +��T�IkS A DEP TMENT USE ONLY AKplcation Accept by �/- Area 5tk 466-67$1 Additional Comments: Lodi 9-3621 Wit'or Grout Inspection by Date li-le r Manteca 823-7104 9 ' Final Inspection by Date �d��: Tracy 835-6385 F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE BASE AMOUNT .DUE AMOUNT REMITTED RECEIVED BY fi DATE PERMIT NO. - INFO EH 13-24 REV. 10/82 10/82 500 14-26 ak _ i