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([C APPLICATION FOR PERMIT 7 /\ iJ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. i 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 Regulations of the San Joaquin Local Health District. Job Address,2 0/'& p ; !S V S n /lf Subdivision Name Owner's Name 'A L& , ;.r=A-S S — Address (p(o P .—aV S- � 0" Phone Contractor's NameftOAXIAr Oe�n,,b 2"04090 ( �4,C 3CaQ P gl Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER t DISTANCE TO NEAREST: SEPTIC TANK ;S�� SEWER LINES -.--- DISPOSAL FLO. PROP. LINE /6 FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti EJ Industrial U Open Bottom [] Manteca s Dia. of Well Excavation / r/ LLrBamestic/Private [ 'ravel Pack Tracy Dia. of Well Casing S �� LJ Public F-1 Other Delta Irrigation Type of Casing Lj 9 Approx. [� Eastern Specifications Q Cathodic Protection Depth Geophysical Depth of Grout Seal (J Other -Type of Grout fV j (1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 3 — •Q State Work Done S Well Destruction U Well Diameter Seali4 Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (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 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 D Depth Size Number SUMPS L_1 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 erson in such manner as to become subject to workman compensation laws of California." Con actor's hiring or sub-contracting ig ture certifies the following: "I certify that in the performance of the work for which this rmit is issued, I shall emplo p rson subject,to workman's compensation laws of California." The ap ant must call for re it in ct' ns. Complete drawing on reverse side. Signed X Title: C'_of Date: ^� FO DEPARTMENT USE ONLY Applic ion Accepted by ) ,-U Area �r Stk 466-6781 . tiLy itional Comments: EJ Lodi 369-3621 Pit or Grout Inspection by _ Date �r 9��7 Manteca 823-7104 Final Inspection by cit Datei��J L Tracy 835-6385 Applicant - Return all copies to: Vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO 4 `rte �2 EH 13-24 REV. 10/82 u `�0/8"L 500 14-26