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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT L �3'2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED• f• a 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 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. Job Address AA, F ;k- e,r 4C/ Subdivision Name Owner's Name ! %c/,s/ S Address AA4'.7:Z .Qct es—ce-40^1 Phone Contractor's Name tr 5,-eV License No. X 66 l`�gE Phone TYPE OF WELL/PUMP WORK: NEW WELL p WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER n 1 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 1-1 Industrial Open Bottom Manteca Dia, of Well Excavation 1-1 Domestic/Private r-1 Gravel Pack F-1 Tracy Dia. of Well Casing 17 Public F-1 Other E]Delta F`1irrigation Approx. []Eastern Type of Casing Depth Specifications M Cathodic Protection 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 ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') ------------- TYPE OF SEPTIC WORK: NEW INSTALLATION J REPAIR/ADDITION 71 (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence X available within 200 feet.)Commercial _ Other � Number of living units: �_ Number of bedrooms 3 Lot size !sAcres Character of soil to a depth of 3 feet: 4 0.99 Water table depth N SEPTIC TANK [7] Type/Mfg ®re G',o0- Gcwc, Capacity 1d9V ' No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line C LEACHING LINE L7J No. & Length of lines .Z Total length/size f0 FILTER BED F-1Distance to nearest: Well igG' ' Foundation ;A C° Property Line SEEPAGE PITS n Depth Size 1'",Y hf r I-r" Number --2- SUMPS 571 Distance to nearest: Well /s c' " Foundation /c ' Property Line S0 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 pyst call for all required inspections. Complete drawing on reverse side. Signed X . . _ Title: _Gti4.- Date: l-�o-Fs3 FOR DEPARTMENT USE ONLY Application Accepted by Area FJ Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by _ Date Manteca 823-7104 Final Inspection by s Date - Tracy 835-6385 Applicant Return all copies to: Environmtc�a " Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 �- �j ' S 10/82 500 14-26 �-�`�