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APPLICATION FOR PERMIT SAN JOAQU-IN LOCAL HEALTH DISTRICT r t1 1601 E. HA7ELT614 AVE., STOCKTON, CA PERMIT NO. $3- l3 i Telephone (209) 456-6781 DATE ISSUED _11A"$� PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED (Complete in Triplicate) _W 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. i Jab Address 226 S . FRF..gN0 _ ' STC)(''KTC)N Subdivision Name Owner's Name (,AT,TF f'F.T) Address 1340 W WASHINGTON, Phone AllCL_ Contractor's Name License No. 7 ti S g F d Phone 4 6 6— 1�_ _ j TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U t PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom [}Manteca Dia. of Well Excavation ! U Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public ri Other Delta Type of Casing L_IIrrigation Approx. ❑ Eastern Specifications rE ❑Cathodic Protection Depth i Depth of Grout seal Geophysical Type of Grout ; U Other Surface Seal Installed by Repair Work Done ❑ 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 ❑ REPAIR/ADDITION U (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 _ Character of soil to a depth of.3 feet: Water table depth SEPTIC TANK Type/Mfg4. Capacity No. Compartments PKG. TREATMENT PLT, Type/Mfg + Capacity Method of Disposal WGE SYSTEM *3 Distance to'nearest: Well Foundation Property Line RUCTION 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 LI Distance to nearest: Well Foundation Property Line i 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 shdll4not employ any person in such manner as to become subject'-to workmanK compensati0n laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which I this permit is issued, I shal employ persons subject to-workman's compensation laws of California," The applicant must f all re fired inspections. Complete drawing on r ver s' _ I Signed x Title: Date: F R p TFE USE O Y Application Accepted by Area —�c / �Stk 465-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 4 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies o: qEtnm. tal nHealth Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FINFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NiO. # o� �'Z— }� FH 13-24 REV. 10/82 6� 10/82 500 A 14-26. j. }