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APPLICATIO FOR PERMIT Pit SAN JOAQUIN LOCAL HEALTH DISTRICT 9 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5-71V 19C 19 C i c7 i4 t/ti Subdivision Name Owner's Name L-- 1,7-e- Address 5"'-7L( Ars_C jg Phone Contractor's Name 795 #Aot/e— License No. e TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION OV}- U J tr✓ t W t PUMP INSTALLATION Q SYSTEM REPAIR �� OTHER r�+vvc v)t /ilk Erna, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. LINE �— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL M AREA CONSTRUCTION SPECIFICATIONS 17 Industrial n Open Bottom gErmanteca Dia. of Well Excavation 1--] Domestic/Private r—I Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta (Irrigation '70/ Approx. E] Eastern Type of Casing Depth Specifications -1 Cathodic Protection p (�Geophysical ov U�- i Y�✓1 (t wG' c ""�� Depth of Grout Seal Other 1 +° `C �2 ihtLci 0.6Type of Grout �ry✓r, f}L-A ft r +01-fel-1 /'rj7 ijl d �f ,° Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') _L TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) ID Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal T Distance to nearest: Well Foundation Property Line LEACHING LINE 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 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 m t ca/l� !for all a fired inspections. Complete drawing on reverse side. Signed X 0 14" 9 Title: �` �� Date: FOR DEPARTMENT USE ONLY X1.2-JL Application Accepted byArea _1 Stk 466-6781 u Additional Comments: Lodi 369-3621 yY,,4h,,-4 Pit or Grout Inspection by _ Date Manteca 823-7104, orf o Final Inspection b ,� y i p Y lu �l f� Date � �7 Z Trac 835-6385 Applicant Return all copied to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 14vi li-1.wv+JJJ dF�'�q(t�fCd FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. Uf( INFO Q c' Irt�l ch p�yr tr- EH 13-24 REV. 10/82 10/82 500 G% 'l3° OrN 4-26 / C;*y