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APPLICATION FOR PERMIT ! SAN JOAQI!N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. (O Telephone (209) 466-6781 7 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appl katior' 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 Sar Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules !f and Regulations ol _> _fr 'the San Joaquin Local Health District. � Job Address ^ �JU, A.0"-i'a�.cll�- ...1" Subdivision Name Jam^ Owner's Name Address e � License No. 2- Phone Contractor's Name �� - j TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR j OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE h FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top .50') Depth Filler Material. (.Be]bw'-SO'} v C WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tark or seepage pit permitted if public sewer is TYPE OF SEPTI +c available within 200 feet.) Installation will serve: ,Resi'dente Commercial Other f Number of living units]�— Number of bedrooms _ Lot ^size f Character of sail toa depth of 3 feet: --2�s�� - Water table depth Capacity a i1 No. Compartments SEPTIC TANK �" Type/Mfg '- p y PYG. TREATMENT PET. ❑ Type/Mfg i Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well !S, /}—Foundation Property Line - DESTRUCTION T r ^ LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well tt'Foundation Property Line SEEPAGE PITS _ Depth Size Number q. s. SUMPS �� Distance to nearest:"Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared"this xlieat'ion 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, 1 shall not employ•any..perso6. in such manner as to become subject to workmank 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." 4 The applicant st call fo al required inspections. Complete drawing Aon�rwerse side. -�- ��,L ,--Z-C Title: �GTJ Date;/ • _ _ Signed X r `O PA 7 USE ONLY 02- Stk 466-67 f Applic ion Accepted by Area Additional Comments:_ �� ❑ Lodi 369-3621 a x fPit or Grout Inspection by Date /3 w� U Manteca 823-7104 Final Inspection by Date -(��' ?5 L7 Tracy 835-63$5 Applicant - Return all copi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ------------ FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �p PERMIT NO. INFO 7 t3 0 — �P 10/82 500 EH 13-24 REV. 10/82 " E_ - _ 14-26 - -