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APPLICATION FOR PERMIT y} try {� SAN JOAQUIN LOCAL HEALTH DIS JUL � i 1983 2 U 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 `", I�' 1y CS DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSILKPIIFEAti i)1S_f'11CT (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 ,5'737 E. /4Sh/f Z-IJSubdivision Name �p X Owner's Name Te,c-,rf A sic cS0,J Address 1,737 4.7-, 4, hl vnit 4- Phone q3/-6 S'6 Q /\ Contractor's Name , License No. ,,,T rJ—l7, Phone 1417.-,r-5 j __ -- OV x TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK OO �� SEWER LINES A a� DISPOSAL FLO. � PROP. LINE \ FOUNDATION 3 OC� AGRICULTURE WELL._ OTHER WELL I SO Pr PITS/SUMPS INTENDED USE TY^E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Zustrial Open Bottom Manteca Dia. of Well Excavation _ estic/Private ❑Gravel Pack Tracy Dia. of Well Casing 0 Public F-1 Other Delta Type of Casing �, irrigation Loo Approx. [] Eastern Depth Specifications F-1CathodicProtection Depth of Grout Seal 17 Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done E] Type of Pump �(Cjv/ H.P. —lam 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 ❑ (No septic tank or seepage pit permitted if puplic sewer is , available within 200 feet.) &J Installation will serve: Residence _ Commercial _ Other .J Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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." 1� The applicant must call or all req d rR�DETMENT tions. Complete drawing on reverse side. J� Signed X ��c , Title: Date: _ USE ONLY j/ Stk 466-6781 Application Accepted by Area Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date El Manteca 823-7104 Final Inspection by -7y1 , Date ? ,j s ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 161 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ;RMIT NO. INFO � EH 13-24 REV. 10/82 c VD 10/82 500 14-26 /� �'