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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED c PERMIT €XPIRES I 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 workherein 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. /ln Job Address etr� r �(lD ) {S�ubdivision Name?V�M ,j� Owner's Name ,Address i.,0 jiQ7( I 0 LJ0_-o-tJkTL_CrL Phone Contractor's Nam `' ' ' �nz,-Ae. License No. Q=a(o - _ Phone TYPE OF WELL/PUMP WORK: NEW'WELL WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS U_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ll" 17 Industrial ❑Open Bottom [ Manteca Dia. of Well Excavation 1-1 Domestic/Private ❑Gravel Pack D Tracy Dia. of Well Casing Public �j Other Delta Type of Casing LjIrrigation Approx. ❑ Eastern Cathodic Protection Depth Specifications Geophysical Depth of Grout seal Other Type of Grout Surface Seal Installed by �O1 Repair Work Done ❑ Type of Pump H.P. State Work Done L� Well Destruction LWell Diameter Sealing Material (top 501) Depth Filler Material (Below 50') d TYPE OF SEPTIC WORK: NEW INSTALLATION U EPAIR ADDITION (No septic tank or seepage pit permitted if public sewer is d available within 200 feet.) Installation will serve: Residence ' Commercial 1,'� Other Number of living units.-� Number of b rooms Lot size Character of soil to a depth of 3 feet: Water table depth �s SEPTIC TANK Cj 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 lines — Q Total length/size FILTER BED Distance to nearest; Well Foundation /0 Property'Line .S SEEPAGE PITS Depth Size Number _ SUMPS IJ 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 K compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "Iscerti-fy-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 ust call f al required inspections. Complete drawing)on(�everse side:. Signed X Title: _ V f a , Dater U�fOR DEPARTMENT USE ONLY Applica ' n Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection byFr �Q Date -,2p 3 EJ Tracy 835-6385 Applicant - Return all copies to: Environmental V alth 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 � � _1� 61 t `'J-&s EH 13-24 REV. 10/82 10/82 500 14-26