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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT s' 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 465-678I DATE ISSUED J-J -17 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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. 544 for sewage or No. 1862 for well/pump and the Rules and Re uIaations of the San Joaquin Local Health District. Jab Address 1299 f S• _CA$741Z Subdivision Name Owner's Name © (�+ S f Address Phone 3 ' X379 / Contractor's Name J01 CAR&,f4-C. License No. Phone. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAR • SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS Industrial ❑ Open B m ❑ Manteca Di of Well Excavation f Domestic/Private ❑Gravel Pack Tracy Dia. Well Casing ❑ Public ❑ Other ❑ a Type of Ca 'ng ❑j irrigation Approx. ❑ Eastern Specification ❑ Cathodic Protectionn�Depth Depth of Grout 5 a ❑ Geophysical e of Grout Other Surfa eal Installed Repair Work Done ❑ Type of Pump H'.P. State Work one Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ` IN. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [ (No septic tank or seepage pit permitted if public sewer is 1� available within 200 feet.) Installation will se Residence _ Commercial _ Othe " Number of living units: Number of bedrooms t size # t Character of soil to a depth 3 feet; *+ Water table depth-l%, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to (''earest: Well Foundation 'Property Line DESTRUCTION ❑ ! ' I LEACHING LINE No. & Length/6f- lines �� '_ Total length/size— FILTER BED ❑ Distance to nearest: Well S��.. Foundatli� roperty Line SEEPAGE PITS ❑ Depth Size Number i I SUMPS Distance to nearest: Well s Foundation �•� P-Property LineE` 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 signature certifies the following: "I certify thatin tfie performance of`the�5ork f6 "wh'ich-thi' i 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-tF6 work for which this permit is issued, I shall employ p rsons subject to workman's compensation laws of California." The applican call for al].,requir�d inspections. Complete drawing on reverse side. /`If �� Signed X �'t+Yj f�7` + Title: NC'f�-- Date: FOR DEPARTMENT USE ONLY �� M k ' ��'' Application Accepted by Area ❑'Stk ' 466-5781 r Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ( ❑ Tracy 835-6385 Replicant - Return all cop to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 - - - FEE• --BASE a-AMOUNT—DUE— ,_AMOUNT REMI7TED.� IRECEjVED BY- DATEx PERMIT N0. IN J� 10/82 500 x EH 13-24 REV. 10/82 -� t 14-26