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APPLICATION FOR PERMIT SAN JOAQU;N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 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. Joh Address .,/9s^�_ w iQ,d/= ��] T+P1Xublivisio, Name Owner's Name Pr T, G/r�w�}�A11e�_!3 ddress y Phone 02? Contractor's Name 4,h, ruGGGP License No. �,°Zr, ,5`$� Phone _�31 6423 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS hJindustrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private F-] Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public F-1 Other ❑ Delta Type of Casing F-71 Irrigation Approx. [] Eastern 'Cathodic Protection Depth Specifications -- -. - ..Depth of Grout Seal � [_�Geophysical Type of Grout U Other 0 Surface. Seal. Installed by Repair Work Done;. _Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sea1i.ng,.Materja.l..Ctop_50'J Depth Filler Material (Below 50') _ TYPE O� SEPTIC WORK:-- NEW INSTALLATIONED REPAIR/ADDITION (No septic-tank or_setpage pit.,p�rmitt-e_d-if,ppblic sewer is available w`ithin•200 feet.) Installation will serve: Residence _1Z Commercial Other10, `, f Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Meth of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ `• I �y LEACHING LINE No. & Length of lines Total length/size f� FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Z2 fT Size 7 ( (/ Number , SUMPS Distance to nearest: 'Well ,1 ?O Foundation fp r 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 to woricmant 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 mustcall far 11 r uiired spections. Complete drawing on reverse' side.' ' a Signed X � _ Title: Date:-FOr:G�c7 R []�ARTMENT USE ONLY Application Accepted by N _ Area _-_ ❑ Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by : Date U Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return-911 copies to: Fnvironm t 1 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. INFO �&s 27&-S- EH 13-24 REV. 10/82 --.: t: •y ..., 10/82 500 14-26 6