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f - n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 73-6 2 1 Telephone (209) 466-6781 ti � DATE I55UED / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ilf (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 J described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No._ 1862 for well/pump I} and the Rules and Re�yulations of the S Joaquin Local Health District. Job Address 4 .0 Subdivision Name Owner's Name k1aaAddress Phone �% �' Y 3 Contractor's ameon�ao- License No. .1-224! _ 7f __ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT - DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK'- SEWER LINES � DISPOSAL FLD. PROP. LINES w FOUNDATION-6g=� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial I—] Open Bottom ❑ Manteca Dia. of Well Excavation . Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing IF1 Public [J Other ❑ Delta Type of Casing U irrigation Approx. L] Eastern Cathodic Protection Depth ; Specifications Depth of Grout Seal Geophysical Type of Grout [GOther 1 Surface Seal Installed by Repair Work Done [ Type of Pump H.P. I State Work Done Well Destruction U Well Diameter Sealing Material {top 50'} Depth Filler Material (.Below 50') i � 3 TYPE OF SEPTIC WORK: NEW INSTALLATION P0 REPAIR/ADDITI J .(No septic tank or seepage pit permitted if publid'sewew is @. Ilk t... 1 11 available within 200 feet.} Installation will serve: Vesidence � Commercial Other Number of living unit: A— Number of bedrooms !/, Lot size 7f',k fZ 3 i _ y� Character'of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg _ Capacity fl No. Compartments _ PKG. TREATMENT PLT. Type/Mfg # ` Capacity Method of Disposal' ' Septid Tanka Distance to nearest: Well Foundation- � r Property Line Destruction LEACHING LINE [J No. & Length of lines f A 75-'ec-&4r4 Total length/size �Jn6 FILTER BED ❑ Distance to nearest:ryei1 Foundation -4 Property Line - - SEEPAGE PITS ❑ Depth Size ,2 Number SUMPS ❑ Distance to nearest i Well A11,4— Foundation Property Line DISPOSAL PONDS rte,; 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 thatrin the performa'nce,of the work for which this permit is issued, •I 061T not'employ any person in such manner-as to become subject to workman t compensation laws of California-" Contractor's hiring or sub-contracting signaturecertifies the following: "I certify that in the performance of the work for which this permit is:,issued,-I shalI employ persons-subject to workman's-compensation laws'of California." The applican must call f all: requir inspections. Complete drawing on reverse side. � l Signed X_ r � u9'Y Title: # - Date: FORD ARTMENT U . ONLY h. Application Accepted by f4Area Stk 466-6781 Additional Comments: Lodi 369-3621 M Pit or Grout Inspection by /_ea,4 04_1-1/-,93 lPj7 Date Manteca B23-7104 Final Inspection by -;Zc Date /y K3 Tracy 835-6385 Applicant - Return all copies to: Env'.r ,on tal Heal Per it/Se'r'vices 1601 E. �I ltan Ave., P.O. Box 2009, Stk., C 95201 t /mep/Ary % A,#*R i A►!A 4;ON 3 Sag t/ld s elf FEE BASE AMOUNT` DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26