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y APPLICATION FOR-PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. r Telephone t2091 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o (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 tJ� and the Rules and Regulations of the San Joaquin Local Health District._ 1 Job Address /7 Subdivision Name . Owner's Nam Address y Phoned Contractor's Name License No. 7 f Phone TYPE OF WELL/PUMP.WORK:• Js x # NEW WELL WELL REPLACEMENT- (] DESTRUCTION PUMP INSTALLATION . SYSTEM REPAIR L OTHER j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL-,, PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom"` ❑Manteca,f Dia. of Well Excavation Lf Domestic/Private Ej Gravel Pack! �.T,racy :7 ➢ia,�of,Well Casing_ 17 Public FJ Other E] Del to s Type of Casing 71 Irrigation Approx.1 Eastern'I`7'. Specifications Cathodic Protection Depth r A S Depth of.Grout Seal ❑Geophysical r Type of Grout',-` LJ Other Surface=Seal'glnstalled by Repair Work Done G Type of Pump H.P. State Work Done rl1 Well Destruction U Well Diameter Sealing Material (top 50') ' k Depth s Frial (Below 50' iller Mate TYPE OF SEPTIC WORK: NEW 3NSTALLR7ION REPAIR/AD➢1TION .[3_.(& septic,tank or seepage pit permitted if public sewer is ---^ = -� available within 200 feet.) s Installation will serve: Residence Commercial _ 'Otherr. .74 v Number of living units: Number of bedrooms Lot size �� fw0��`.Z 7 Character of soil to a depth of 3 feet:, Water table depth 1670 SEPTIC TANK Type/Mfg--� r '^ z Capacity No. Compartments PKG. TREATMENT PLT, Type/Mfg 1 Capacity Method of Disposal SEWAGE SYSTEM .Distance to nearest: Well 4F - Foundation 110 Property Line ^� DESTRUCTION i y LEACHING LINE No. & Length of lines. 3 ` 6 Total length/size , FILTER BED � Distance to nearest: Well f3-0 ourdatior Property Line So SEEPAGE PITS Depth 2 S' Sized Number SUMPS Distance to nearest: Well _s b VE round_ation Property Line 74 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 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 st call fo al quiredi.inspections. Complete drawing on reverse side. t Date: SignTitle:ed X ` � D RTML USE ONLY Application Accepted by r Area Stk 466-6781 i Additional Comments: 1470 Lodi 3 3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by 10e.7 Date rY3 L Tracy 835-6365 Applicant - Return all copies to: Environmertal Health Permit/Services IfiOI 'E: Hazelton AveT,`P:O Box-2009-5tk=, CA 95201 f I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i INFO l I EH 13-24 REV. 10182 A/ ��-_ / � � �� 10/82 500 i 14-26