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I APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. 8,3 Y //-7 Telephone (209) 466-578I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED � p2 r (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 Regulati ns of t San Joaquin Loca Health Di ict. Job Address tF 46 1 g- MAIL - am Owner's Name Add ess 777 Phone Contractor's Name 00cp,g .0 r cense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION OU .' PUMP INSTALLATION SYSTEM REPAIR OTHER Lf 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 SPECIFICATIONS1-1 -� Industrial ❑ Open Bottom E]Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public ❑ Other Delta VIrrigation Type of Casing + Approx. Eastern + El Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal ❑Other Type of Grout { Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done , Well Destruction 0 WelI,A ameter Sealing Material (top 60') ^- Depth Filler Material (Below 50') OR TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence Commercial _ Other available within 200 feet.) �Number of living units: _1_ Number of bedrooms — Lot size P" 7 ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg �l 4_Capaclt _ t7 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of)Disposal T M SEWAGE SYSTEM Distance to nearest: Well P Foundation Property Li`n-tee Q DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size �l FILTER BED Distance to nearest: Well / f)j0 Foundation Proper ine SEEPAGE PITS ❑ Depth Size '" Number SUMPS L" Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� 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 Is 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 applican mu foL.4 1 required spec tions. /mVlete drawing on reverse side. Signed X 3e: Date: ' rr FO A T E USE ONLY / -7 'Application Accepted6y (Ar� iX_ Area ! y E3 Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by �- �j R�(� 9 Date i _3 L7 Tracy 835-6385 Applicant - Return all copie� to: Fnvironmen al Health Permit/Services 1601-E. Hazelton Ave:! P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED„BYw_ DATE PERMIT NO, INFO 00 EH 13-24 REV. 10/82 10/82 500 14-26