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lko� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 /'7�N, SQL&AIZ Qb Subdivision Name Owner's Name 1C_�y Address ,$,tJlyJr Phone V,:fZ—J/'y4- Contractor's Name A7Le$&j> j5. W,&40,6 License No. � 7T�j/� Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1_J Industrial U Open Bottom [] Manteca Dia. of Well Excavation LJ Domestic/Private F� Gravel Pack F_� Tracy Dia. of Well Casing 0 Public CJ Other E] Delta Type of Casing [ j Irrigation Approx. E] Eastern Specifications F—ICathodic Protection Depth Depth of Grout Seal 0 ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION j (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: C ",Ja Water table depth SEPTIC TANK 2� Type/Mfg r — q-1— Capacity /7,00 No. Compartments 2,et,!� PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well :5jQ Foundation J„E7' Property Line _ DESTRUCTION LEACHING LINE No. & Length of lines Total length/size d r41� X Z FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS r Depth _ Size ® � ri Number SUMPS Distance to nearest: Well %OQ Foundation '-Q 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 workmanIs 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 11 for all requir inspections. Complete drawing on reverse side. Signed X aAl Title: Date: *"�l✓ �� FOR DEPARTMENT USE ONLY Application Accepted by Area 62�— �tk 466-6781 Additional Comments: ' [] Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies o: Enviro ental Health Permit/Services 1601 H el ton P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED FEED BY DATE PERMIT NO. INFO 1 '1 10/82 500 EH 13-24 REV. 10/82 14-26