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APPLICATION FOR PERMITI ' SAN JOAQLiN LOCAL HEALTH DIS p 1501 E. HAZELTON AVE., STOCKTON, CA I = 3.3_k PERMIT N0. Y3— I�� ,{ 7 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSU .AN OAQUiN LOCAL (Complete in Triplicate) 14MTH 09STR1CT 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation of the San Joaquin Local Health District. Job Address /„/„/) - 13 A Subdivision Name Owner's Name I�Oi?__. Address ,4dAo T u/ Phone Contractor's Nam License No. (� 7 w qlo Phone �rf/ ��f® e 06 TYPE OF WELL/PUMP WORK: NEW WELL Q ? WELL REPLACEMENT DESTRUCTION 1 PUMP INSTALLATION rV SYSTEM REPAIR ] OTHER U [fJ 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 SPECIFICATIONS �N FlIndustrial U Open Bottom ❑ Manteca Dia. of Well Excavation V U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public CjOther Delta Type of Casing Li Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal U Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump Ae�f� N.P. State Work Done ,/�,t�� ,,/L Well Destruction F_ Well Diameter Sealing Material (top 50') �� 77""��-" Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/.ADDITION U (No septic tank or seepage pit permitted if public sewer is C�> — available within 200 feet.) r Installation will serve: Residence Commercial Other &} Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [J_ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L 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, 1 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: /�ig ��_!i_�-��A/ Date: , FOR MTMENT USE ONLY Application Accepted by rVA Area 0 Stk 466-6181 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 Permit/Services 1601 E. Hazeltor Ave., P.O. Sox 2004, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26