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APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, Telephone (209) 466-678I p DATE ISSUED,5//7 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, Job Address // ' Address— `_.1O/ � � �;� ��. Subdivision Name Owner's Name _ 7o—o— a4cp;„ Address Phone Contractor's Name — QMeJ1 J X License No. Phone �F TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION W PUMP INSITALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK,11 SEWER LINES DISPOSAL FLD. PROP. LINE CIO FOUNDATION AGRICULTURE WELL OTHER.WELL PITS/SUMPS r y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W !] Industrial ❑ Open Bottom Manteca Dia. of Well Excavation LJ Domestic/Private ❑ GraMvei Pack Tracy Dia. of Well Casing . ❑ Public ❑ Ot4'r Delta Irrigation I`: Type of Casing , IRpprox. Eastern Specifications n Cathodic Protection Depth [J Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by i Repair Work none Type of Pump H.P. State Work Done —� Well Destruction U Well Diameter Sealing Material (top 50') Depth �� Filler Material (Below 50') sr TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION JV (No septic tank or seepage pit permitted if public sewer is IM available within 200 feet.) Installation will serve: Residence Commercial _ Other �� ~ Number of living units: Number of bedrooms - Lot size / /Z lie, Character of sail to a depth of 3 feet: r4ii'f Water table depth SEPTIC TANK Type/Mfg Capacity �/ a p No. Compartments 72— PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well y� Foundation Property Line DESTRUCTION ❑ I� LEACHING LINE No. & Lfength of lines 3 "— Total length/size 170 FILTER BED Distance to nearest: Well Foundation Property Line rt SEEPAGE PITS Depth 12 Size 3 3 Number 7 ; SUMPS Distance to nearest: Well /00 Foundation Property Line DISPOSAL PONDS ❑ ¢ 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 shallnot 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 must call for all required inspections. Complete drawing on r vexse side , / Signed X ` Title: �� } � �`� Date: iy--- MENT USE ONLY Application Accepted by ry: Area 161 y Stk 466-6781 Additional Comments: /51 Lodi 369-3621 Pit or Grout Inspection by Date S 1/Z �� Manteca 823-7104 It Final Inspection by DateS/7 ' fl� L Tracy 835-6385 Applicant - Return all copies to Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CR 95201 Ih P FEE AMOUNT ]DUE AMOUNT REMITTED RECEIVED BY DRTE,p g7PERMIT N0. INFD f� 03 EH 13-24 REV. 10182 10/82 500 14-26