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APPLICATION FOR PERMIT SAN JOAQUik LOCAL HEALTH DISTRICT sC 3 — 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �y Q Telephone (209) 466-67BI DATE ISSUED I� PERMIT EXPIRES 1,YEAR FROM DATE.ISSUED (Complete in Triplicate) . Health District for a permit to construct and/or install the work herein Application is hereby made to the San Joaquin Local with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump described. This application is made in compliance and the Rules and Regulations of the San Joaquin Local Health District, Job Address 2Z�g% « Ac 'DQ Subdivision Name. Address ."W. Phone Owner's Name .TA Phone - Contractor's Name T _� �— License No. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT;j[� LT DESTRUCTION r PUMP INSTALLATION SYSTEM REPAIR � OTHER, SEWER LINES DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - FOUNDATION AGRICULTllRE WELL OTHER WELL PITS/SUMP-S,-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS = "� U Open Bottom [] Manteca Dia, of Well Excavation Industrial r ..� L 1 Domestic/Private Gravel Pack ❑ Tracy Dia ,�,rbf Well Casing } Public Other Delta Type of Casing Lj Irrigation Approx. [] Eastern Specifications Depth ' Cathodic Protection Depth of Grout Seal Geophysical Type of Grout ..- -- -- Y•-'---- `- U Other Surface Seal Installed by 'r Repair Work Done Type of Pump H P, State Work Done 1 _ Material (tap 50') Well Destruction Lj Well Diameter Sealing Depth Filler Material (Below I it permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/.ADDITION (.No septic tank�or seepage pit within 200 feet.) Installation will serve: Residence Commercial i Other Number of living units: �__ Number of bedrooms Lot size Z 7 _ �" Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK �j Type/Mfg / Capacity r Capacity Method of Disposal PKG. TREATMENT PLT. Type/Mfg Property Line SEWAGE SYSTEM Distance to nearest: Well -J- Foundation DESTRUCTION f -'ior No. � Length of lines- L Total length/size Q Z LEACHING LINE g �,_v Foundation r � �-` Property,Line_�_ FILTER'8ED�-� �-<- Distance-to,nearest:,--Wel l- �.-'� =-= ` - SEEPAGE PITS epth �� ; �, ^); Propert Line i SUMPS Disfdnce to nearest: We1T ri }oundation, y w a DISPOSAL PONDS 01 ¢ s that the work will be done in accordance with San Joaquin county I hereby certify that I have prepared this application and and and regulations of the San Joaquin Local Health District. of the wlawsfof ordinances, state laws, rules that ntohworkman� s the following: licensed agent's signature Certifies compensationerformance California." Home owner or to becomeysubject is issued, I shall not employ any p g:-„ that in the of the work for whit the permit Contractor's hiring or.sub-contracting certifies slccomnensationrlaws p this permit is issued, --I shall employ p ' Complete drawing on reverse side. The applicant must call f all required spections. Date. Title: - Signed X FOR DEPA N t E] Stk 466-6781 Area Application Accepted by � � � Lodi 369-3621 Additional Comm is Manteca 8237104 Pit or Grout Inspect n by R t Date 1 A 00, Tracy 835-6385 Date Final Inspection by Environmental ealt� Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 Applicant - Return all copies to:. 'k AMOUNT REMITTED RECEIVED BY �— DATE ..kPERMIT N0. - FEE BASE RMOUN7 DUE INFO e , 10/82 500 EH 13-24 REV. 10/8214-26 g,