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( 6V,h )0, 6k. APPLICATION FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT 1601 £. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6181 DATE ISSUED PERMIT EXPIRES I-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mdde"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 AddressaSubdivision Name Owner's Name `Dn _r IRd/7C Address ,ag Phone Contractor's Name Sw-awe'd R&OV License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑f (1-3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca r 1 9ia.�of Well Excavation ❑ Domestic/Private ❑ Gravel Pdck ❑Tracy 1 Dia. of Well Casing ❑ Public ❑ Other ❑ Delta M. Type of Casing y yj Irrigation Approx. ❑ Eastern Specifications Cathodic Protection � ❑ Depth Depth of Grout Seal € ❑Geophysical Type of Grout ❑Other Surface Seal Installed by _ i Repair Work Done R Type of Pump �H.P. 42) State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 d Depth Filler Materia d(Below%0')_ - - t; p, 1`7- Z> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ❑ (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 size r Character of soil to a depth of 3 feet: `� Water table.depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments 1 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ~" "' , .Distance_to,nearest: ,Well— —.Foundation Property-Line DESTRUCTION r. LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well'":M "Foundation Property Line ` SEEPAGE PITS Cj Depth Size Number M SUMPS U Distance to nearest: Well Foundation Property Line 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." 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 1 re it pection Complete drawing on reverse side. Signed X '�de�+� itle: 466- Area Std Date: NT ONLY O ❑ , Application Accepted b 3621 4 Additional Comments: ❑ Lodi 369-3121 k Pit or Grout Inspection by Date Manteca 623-7104 i Date �� / ' ❑ Tracy 835-6385 Final Inspection by Applicant - Return all copie . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Fee- 10/82 500 EH 13-24 REV. 10/82 14-26