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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �p f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 4 —� Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM GATE 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 �3 /6/� - Subdivision Name Owner's Name �,�,�� _L &JZC� D Address Phone JAJ�,#— 2 7516 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --•J FlIndustrial U Open Bottom ❑Manteca Dia. of Well Excavation L7 Domestic/Private Q Gravel Pack []Tracy Dia. of Well Casing r Public E] Other E] Delta Type of Casing L ! Irrigation Approx. Eastern Specifications t Cathodic Protection Depth Depth of Grout Seal Geophysical y . * U Other Type of Grout Surface Seal Installed by f Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REP RR APOE tg (No septic tank or seepage pit permitted if public sewer is 4 Installation will serve: Residence )( Commerciat _ Other available within 200 feet.) Number of living units: Number of bedrooms �^ Lot size x 1.00 i Character of soil to a depth of 3 feet: /4P8$4L— Water table depth X® 77, t SEPTIC TANK U Type/Mfg Capacity No. Compartments — PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line c a 6 LEACHING LINE ( No. & Length of lines Total length/size ZS/ _ --A'064464NE FILTER BED '�� Distance to nearest; Well Foundation �� S Property Line `] SEEPAGE PITS Depth Size Number f SUMPS Distance to nearest: Well Foundation .2S"/ Property Line --A:— 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." r Contractor's hiring,or sub-contracting si at- re certifies the following: "I certify that in the performance of the work for which M this permit is sued, 1 shall employ p sons subject to workman's compensation laws of California." The applic 1..for 1 re ��inspections. Complete draw' n reverse side. _� i Signed XdKAMy4w go �. Title: T_ s�� Date: FOR A NT USE ONLY �n Application Accepted by Area IwStk 466-6781 Additional Comments: F-1 Lodi 369.3621 Pit or Grout Inspection by _ Date Manteca 823-7104 Final Inspection by. Date Tracy 835-6385 Applicant - Return all copies o• n 1 1 /C Services 601 E. Hazelton ve., P.0 Box 2009, Stk. �C 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8 GATE PERMI NO. INFO . w 'EH 13-24 REV. 10/82 10/82 500 14-26