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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZELTON A"E., STOCKTON, CA PERMIT NO. " Telephone f209) 4T-6781 DATE ISSUED 1 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 .ZZIYO C J4e,ste25&Q Subdivision Name Owner's NameSr & Address .#/� Phone Contractor's Name License No. 3 !V-3 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION F-1 SYSTEM REPAIR OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial u Open Bottom F-1 Manteca Dia. of Well Excavation 1-1 Domestic/Private F�Gravel Pack Tracy Dia. of Well Casing 17 Public [j Other Delta Type of Casing U Irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal �jOther Type of Grout Surface Seal Installed by Repair Work Donei Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence L'�'r Commercial _ Other =� Number of living units: f Number of bedrooms 'y�_ Lot size —40 114i°'s�y,f 1;4-_ C) Character of soil to a depth of 3 feet: iq�1QrJi' Water table depth 2.y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lint`Zp L Total length/size Q FILTER BED Distance to nearest: We1T,16-0_ Foundation iy Property Line SEEPAGE PITS Depth Size Number Z— SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cj 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 ca]l fop all rdµ.red ' sp cti . Complete drawing on2reverse s'*. Signed X Title: s-� Date: 1 FOR T T USE ONLY Application Accepted by Area r—> _ Stk 466-6781 Additional Comments: U Lodi 369-3621 Pit or Grout Inspection bi _ Date Manteca 823-7104 Final Inspection by J Date (Q �'�' Tracy 835-6385 Applicant - Return all copie to: Env ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., .CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i 4b EH 13-24 REV. 10/82 10/82 500 14-26