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APPLICATION'FOR PERMIT » -. . -- -,._ •. :_ SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �� 0 Telephone (209) 466=6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED -b . (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, I Job Address I �/,W/mss Subdivision Name.. - Owner's Name �L_��Q�� si� Address Phone Contractor's Name 64-67Y0 ::4r. . ®@_V License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE [ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca E�] ❑ Dia. of Well Excavation 111N� ❑ Domestic/Private E]'Gravel Pack ❑ Tracy , �Dia. of Well Casing k Public ❑Other Delta r `❑ Irrigation Approx. Type of Casing ~Eastern Cathodic Protection Depth Specifications tDepth of Grout Seal `^ Geophysical � ;u � U Other 13 Type of Grout ' .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 Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATLON_L�_,,,..REPAI.R/ADDI-TION-,�(_No,septic tank or seepage pit permitted�i.f;public sewer is f ` Installation will serve: Residence ✓ Commercial Other available within,200 feet.)v, v Number of living units: �-__y Number of bedrooms '� Lot size S, Character of soil to a depth of h feet: L�L i 4 'AL Water table depth _ } SEPTIC TANK T e YP /Mfg Capacity r No. Compartments I PKG. TREATMENT PLT, ❑ Type/Mfg Y Capac4t5' Method of Disposal 'A? SEWAGE SYSTEM Distance to nearest: Well Foundation' i f, Property Line DESTRUCTION Eli. k LEACHING LINE U No.'& Length of lines -:Total-..;Total length/size FILTER BED Distancetoneearest: Well , Faun.datiot Property Line _ SEEPAGE PITS Depth 9 p ��Q size . s` �Number%. f SUMPS Distance to nearest: Well _ Fa undati6n JO W Property Line j DISPOSAL PONDS A u f "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 regulationsw61`,jhe San Joaquin Local Heal th,District. Home owner or licensed agent's,si`gnature:cer-ti-fies the-fol-l6wing:r- 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-foll-owing:. "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 vf-California." The applicant must call for all 'requ -red inspections. Complete drawin on reverse side Signed X ` �::: '�, Title: � y Date: FOR DEPART ll 0 Application Accepted by ea 5Lk 466-6781 Additional Comments- ` ` Lodi 369-3621 1 -or Grout Inspe on by at Manteca 823-7104 Final Inspection by Date Y� Tracy 835-6385 Applicant - Return all cap' s o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO i EH 13-24 REV. 10/82 10/82 500 i 14-26 " a r