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k APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT f 1501 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT N0, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DALE ISSUED (Complete in Triplicate) 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. Job Address :Z/ ''}cf q 5. C,, 4 _/7�vrC�v�v /iW Owner's Name 7b � Subdivision Name AIYA�lAddress Contractor's Name % elY v'83 A-4> -c- /7W Phone License i No. yg/y-0'V/ Phone -.x3'- %2 TYPE OF WELL/PUMP WORK: NEW WELL ! ❑ WELL REPLACEMENT [] DESTRUCTION ❑ - _r` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE Y, FOUNDATION AGRICULTURE WELL OTHER WELL1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAl� CONSTRUCTION SPECIFICATIONS F n II J Industrial U Open BottomManteca F-1 Gravel ❑ Dia. of Well-Excavation ❑Gravel Pack ❑ Tracy Dia. of Well Casing 17 Public ❑ Other ❑ De7ta J,,&� —`�- Irrigation Type of C�"sing Approx. ❑ Eastern i ❑ Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal LJ Other Type of Grout 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump € H.p State Work Done Well Destruction ❑ Well Diameter 1 sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION j (No se tic tank or seepage � Ppit permitted if public sewer is J Installation will serve: Residence X w Commercial _ Other available within 200 feet.) Number of living units: / Number of bedrooms _V' Lot size / oc;p e Character of soil to a depth of 3 feet: f Water table depth 44?` SEPTIC TANK D Type/Mfg A-' n4jr7- Capacity /. f3a P y No. Compartments ;1. PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Ei Distance to nearest: Well drd Foundation. ,Z S Property Line DESTRUCTION LEACHING LINE No. & Length of lines 7 - 90 Total length/size .2 ;;�v FILTER BED ❑ Distance to nearest: Well /D4 Foundation l!O' Property Line ;Z 5- SEEPAGE SEEPAGE PITS I Depth a Size Number SUMPS ❑� Distance to nearest: Well Foundation e 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 tv 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, t Signed X wl10 ff z Tit e: Date: 3---4 FOR EP ENT ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection bye � Manteca 823-7104 Final inspection by �.-� Date �/ Tracy 835-6385 Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. H zeltor Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE x AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. 1 INFO EH 13-24 REV. 10/82 14-26 10/82 500