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i APPLICATION FOR PERM_T SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 S^ T r✓ / Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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. 9/ Job Address /66uly Z7/` ;;111Z41LZ4Z Subdivision Name Owner's Name 42L�j/z _5G5,0 70f Address Phone Contractor's Name �.�//'j,s+S License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U pa PUMP INSTALLATION SYSTEM REPAIR LJ OTHER U G,l 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 Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack [] Tracy Dia. of Well Casing ❑ Public Other Delta Type of Casing L Irrigation Approx. Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal 0 Geophysical Type of Grout 17 Other Surface Seal Installed by Repair Work Done G 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 INSTALLATION ❑ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence < Commercial �Other Number of living units: Number of bedrooms _ Lot siz�/�S Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 4f r,. i r Capacity /2Z7 L-a No. Compartments Z_ PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well go `Foundation -6110 - Property Line DESTRUCTION Q Total len th LEACHING LINE No. & Length of lines p g /size yC FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth �S T Size Number SUMPS U Distance to nearest: Well 3top Z Foundation Property Line DISPOSAL PONDS CI 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 fallowing: "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 a 1 req ed i c ions. Complete draw on reverse ide. 00 Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Area92— �' Stk 466-6781 Additional Comments: L Lodi 369-3621 Pit or Grout Inspection by Date �a`6'fs LJ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Envirormertal Health Permit/Services 1601 E. Hazeltor Ave., P.D. Box 2009; Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY l_DATE PERMIT N/0. Q INFO lCy SCJ 03 10/82 500 £H 13-24 REV. 10/82 14-26