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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 c� DATE ISSUED Jr"S'"3 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 '1 sy APAOJJ�e p e � Subdivision Name Owner's Name N, SCMU[7_-z Address Az Phone f3i-11702- Contractor's Name F.'� �fj � �Q�� License No. Phone ��-337 / TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION E] SYSTEM REPAIR OTHER 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 FI Industrial U Open Bottom 7 Manteca Dia, of Well Excavation r^; L.) Domestic/Private f_1 Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta Lj Irrigation Approx. EJ Eastern Type of Casing ❑Cathodic Protection Depth17 Specifications Depth of Grout Seal �- Geophysical � Type of Grout 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 [Z (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence .J� , emmercial _ Other Number of living units: r� r of bedrooms Lot size 1� Character of soil t J3 feet: Water table depth �y SEPTIC TANK pe/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal W SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size .t�e ke Z j FILTER BED Distance to nearest: Well i Z 1Foundation 1.0 i Property Line SEEPAGE PITS Depth A4�_I-- Size Lj.�4 Number I SUMPS Distance to nearest: Well ) Q Foundation 2f Property Line 249 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 call for 1 required in pections. Complete dr wing on reverse side. ..� Signed X Title: Date: a —.� F DEP MENT USE ONLY Application Accepted by Area _ NStk 466-6781 Additional Comments: EJ Lodi 369-3621 Pit or Grout Inspection by L Date 'jV' ' Manteca 823-7104 FinalInspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental 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 EH 13-24 REV. 10/82 10/82 500 14-26