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APPLICATION FOR".PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. V 7 3 — Telephone (209) 466"-6781 DATE ISSUED 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,Fob AddressT�-1)t(„3. .. G7'/,SM�/f` �� Subdivision Name Owner's Name OA V,9 Sf'Ji j-/� Address Phone I Contractor's Name G7_, A4!T/fe-y< 8O-SGiY License No. /�6—S'�� Phoneme TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 111 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑J Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑ Eastern Depth Specifications L] Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout " ❑}Other Surface Seal Installed by. r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Mater.-ia1' Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other �J Number of living units: f Number of bedrooms 3 Lot size Character of soil to a depth of 3 feet; IC-0,9AW Water table depth SEPTIC TANK Tjj Type/Mfg /DYE G,4 s 7' Capacity D O No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal �J i SEWAGE SYSTEM ❑ Distance to nearest: Well F0' Foundation 2 10 Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well __g�e Foundation /C ' Property Line O f SEEPAGE PITS ❑j Depth Size Number SUMPS ❑` Distance"to nearest: Well Foundation Property Line DISPOSAL PONDS ❑i 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 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 mus call for all required inspections. Complete drawing on reverse side. u Signed X W ATitle: Date: FO VRTMENT USE ONLY �f Application Accepted by Area ( ED Stk 466-6781 Additional Comments: S _�yJ� ❑ Lodi 369-3621 Pit or Grout Inspection by f Date L-1 Manteca 823-7104 Final Inspection by _ dL Date AV ❑ Tracy 835-6385 Applicant - Return all copies to: Environmfetal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED' RECEIVED BY DATE PERMIT NO. INFp tl EH 13-24 REV. 10/82 10/82 500 14-26 i