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"N APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 DATE ISSUED 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. 1662 for well/pump and the Rules and Regulation of the San.Joaquin Local Health District. ' A Sob Address 1p�/ I'- �j% 571,&, !!!�T .cl Subdivision Name 19 $Vl— Owner's Name t p ` Address Phone -5-1 3 J Contractor's Name /,j License No, As%� 3 Phone tl"=%n) ` TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U a PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ ) DISTANCE TO NEAREST: SEPTIC TANK .y SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y F-1 Industrial [-1Open Bottom 71 Manteca Dia. of Well Excavation LJ Domestic/Private F-1 Gravel Pack { Tracy Dia, of Well Casing 17 Public F-1 Other E] Delta Type of Casing N V Irrigation Approx. Eastern Cathodic Protection Depth Specifications L7 Geophysical Depth of Grout Seal Type of Grout �-- Other Surface Seal Installed by C7, Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') j Depth Filler Material (Below 50') v l TYPE OF SEPTIC WORK: NEW INSTALLATION [l REPAIR/,ADDITION 7� (No septic tank or seepage pit permitted if public sewer is % Q . { N ""�'� available within 200 feet.) w Installation will serve: Residence Commercial _ Other Number of living units: _ Number of bedrooms _ Lot size f-S--w- I xZ1 . Character of so'I to depth of 3-feet: �� Water table depth SEPTIC TANK Type/Mfg �/VG apacity fat QQ No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation �1p! Property Line In OLSTRUCTION Q LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number } SUMPS LJ Distance to nearest: Well Foundation Property Line d DISPOSAL PONDS e 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. 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issu d, I shall not employ any person in.such manner as to become subject to workman compensation laws of California." Contractor's ring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i sued; I shall employ ersons subject to workman's compensation laws of California." The ap)Ii n call r all re red inspections. Complete in on reverse de. Signed Title: Date: F DEP ENT USE ONLY Application 'Accepted by iec.��' Area f Stk 466-6781 Additional Comments: Lodi 369-3621 G Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by ° Date ❑ Tracy 835-6385 Applicant - Return all copies to; . En it rmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 0� ~I. 75 E : r EH 13-24 REV, 10/82 10/82 500 14-26 l