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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /PERMIT N0. -7 1601 E. HAZELTON AVE., STOCKTON, CA — l� ,O I '} ` Telephone (209) 466-6781 DATE ISSUED o AY vvv 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 lA rrfl U 5 Z ICZ b Subdivision Name Owner's Name d ZI eA y @ w Address Phone Contractor's Name , , 1L,�p License No. 7 ,5 Pie O� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT (] DESTRUCTION[J PUMP INSTALLATION ❑ SYSTEM REPAIR [] OTHER ❑ 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 J ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private F-1 Gravel Pack ®Tracy Dia. of Well Casing 1 PublicEj Other ❑DeltaF—1Type of Casing a Irrigation Approx. ❑Eastern Specifications Depth Cathodic Protection ' ❑ Depth of Grout Seat ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done Ell Type of Pump H.P. State Work Done pJ Well Destruction (J Well Diameter Sealing Material (top 501) p� Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION J=J REPAIR/ADDITION � (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 bedroomsLot size Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Septic Tanka Distance to nearest: Well 10 Foundation 3p Property Line .DG ruc -_ - LEACHING LINE Lid No. & Length of lines Total length/sized �T FILTER BED F-1Distance to nearest: Well 04rer'CO I Foundation Property Line SEEPAGE PITS Ej Depth j Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ — *********�� srrrrs�-rr-c•s•s i 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 must call r a req . ed inspections. Complete drawing on reverse side. SignedX_ . Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by _ _ Area ❑ Stk 466-6781 Additional Comments: - _ ❑ Lodi 369-3621 Pit or Grout Inspection by Date 0 Manteca 623-7104 Final Inspection by Date 7�f- ,� ❑ Tracy 836-6386 Applicant - Return all copies os Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV, 10/82 10/82 500 14-26