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139 APPLICATION FOR PERMIT ISAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,, CA PERMIT NO. � Telephone (209) 466-6781 DATE ISSUED ' 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 Regulat' ns of the Sa Joaquin Local Health Dit ict. Job Address / 6 .�J N Subdivision'vision Name Owner's Name Z A res /� Q . i.w Phone ' u� r Contractor's Name icense No. _3�d 3 �l Phone � �- 124 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �J _ 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 Industrial f—1 Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing L, irrigation Approx. [] Eastern Specifications Cathodic Protection Depth F-1Cathodicof Grout Seal � ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ 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 public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: �_ Num er o bedrooms Lot size y(1C: Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity j Z `v'C No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation /(� Property Line [� DESTRUCTION LEACHING LINE No. & Length of lines Total len�h/size Z%Q -- y' FILTER BED ❑ Distance to nearest: Welloundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 applicanl,49st call for-07*required i pe tions. Complete draw in reverse side. Date: � ��4? Signed X� (T ,�� Title: R DEPART T USE ONL466-6781 Application Accepted by S' Area _ '916, Stk❑ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date 1>1<' anteca 823-7104 6 Final' Inspection by �i i Date Z l ❑ Tracy 83.5-6385 v Applicant Return all copies o: nvironmental Health Permit/Services 1601 E. Hazeltoh Ave., P.O. Box 2009; Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE } PERMIT NO. J \� 51 10/82 500 EH 13-24 REV. 10/82 v' 14-26