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APPLICATION FOR PERMIT SAN JOA.QU;h LOCAL HEALTH J:STR.ICT 1601 E. HAZELTON, A,VE '; STOCKTON' CA PERMIT NO. �J�J3fo M Telephone(209) 466-6781 DATE ISSUED c x PERMIT EXPIRES 1 YEAR FROM DATE 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 ,oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Jo quip ocalrHealth District. t Job Address_�If/9C•3 !V i � Subdivision �Name Owner's Name ,,fi�nn G�sal-'A-rr Address {• 0I mlt_C ` . eC_�IY _ - Phone 3 —1310 Contractor's Namq[2" CLicense No.- 'Z Z1; (,r Phone yS t TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �: w -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE {� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f4 l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation 1! t❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing k ;❑ Public ❑ Ot t -t „ " E] Del to ., nType of Casing V Irrigation App-Fox. il ❑ Eastern Specifications 1 E❑Cathodic Protection Depth. Depth of Grout Seal I❑Geophysical �J Type of Grout '� • r L"_ Other k f � Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State-Work Done i Well Qe"struction [—IWell Diameter Sealing Material (top 50') Dj ptht� , r f Filler Material (Below 50') STYPE OFrSEPTIC WORK: NFW IN$TALLATIOW-b REPAIR/!ADDITION NO Septiq tank or seepage pit-permitted"if public"sewer is available within 200 feet,) I - Installation will serve: Residence ^/�Commerci:al _ Other F h ' �iNumber of living units: � Number of bedroom"s �J� Lot size � .Character of soil. to a depth of 3 feet: Water table depth C SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i P`G.,.TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: WeIY ' Foundation Property Line ! _,DESTRUCT ION LEACHING LINE � �❑ No. & Length of lines ” ~--Total'length/size FILTER BED ❑ Distance to nearest: Well Foundation PFoperty..L.iner ,d } SEEPAGE'PITS [j Depth Size' 4 SUMPS Distance to nearest: Well -/O Ir Founda f. on i d z�- Property Line DISPOSAL PONDS -❑ i 1!1 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 t 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 applican must c4,,H f all required inspections. Complete drawing o reverse side. { Signed K lJJ� Title: Date: r FO DEPARTMENT USE NLY Appli ion Accepted by Area 1 ❑ Stk 466-5781 Additio%J Comments: A?' Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by I/ Oate ❑ Tracy 835-6385' Applicant - Return all copies to: Environments Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. F INFO r�. 3-33� I EH 13-24 REV. 10/82 � `�' �?-Y1 r Z 4- B2 500 i 14-26