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APPLICATION FOR PERMIT t. Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE I55U£D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 RdAe_4.7- L Y Subdivision Name Owner's Name �L=_ " Address S Phone Contractor's Name �!�Ty� &PagD License No: L�Zjr�]� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE } TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONLS 1-1 Industrial ❑ Open Bottom ❑Manteca `Dia, of Well Excavation _ Domestic/Private -❑Gravel Pack ❑ Tracy f�Dia. of Well Casing Public ` F-i Other Delta F Type of Casing FJ Irrigation Approx. ❑Eastern Depth of F-1Cathodic Protection.._.- p i :Depth of Grout Seal i ❑Geophysical s Type of Grout F ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump -`:'H.P.A State Work Done Well Destruction ❑ Well Diameter Sealing Material (top501o) Depth Filler Material (Below 501) _ 0 TYPE OF SEPTIC WORK: NEW U RE INSTALLATION PAIR/ADDITION +�(No septic tank or seepage pit permitted if public sewer is ' : available within 200 feet.) Installation will serve: 'Residence°� Commercial _ Other Number of living units ,r Number of bedrooms Z Lot size $p X ZG P 14, Character of soil to epth of 3. feet: Water table depth SEPTIC TANK , Type/Mfg 'P —e,- Capacity J 7-ep 0 No. Compartments 2 � PKG. TREATMENTIPLT. ❑ Type/Mfg 'ef i Capacity Method of Disposal Septic Tank '� 00 Distance to nearest: Well' 7 Foundation. /Q Property Line L ®j Destruction _ �, f. LEACHING LINE r` �/s�� ngth of lines j Total length/size FILTER BED rix 3 Distance'to nearest '.Wel ,, -' ""'""'—Foundation .,i Property Line SEEPAGE PITS ❑ s Depth =. L-""Size—' Number SUMPS ❑ 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 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 workmant 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;compensat ion laws of California." The applicant must call f r allerequired inspections. Complete dr wing on reverse side. Signed X � Title: _ Date: F EP E TON F ^ Application Accepted by `� Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by / Date �� ❑ Tracy 835-6385 Applicant - Return all copies-to:--Environmental-Health-PermitISerVi`ce's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE v ti AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. -Ibt EH 13-24 REV. 10/82 10/82 500 J k 14-2b v/