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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone-(209) 466-6781 I ��r 2 DATE ISSUED .0 . (O DJ 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. ® i Job Address bjml kA-r t& Subdivision�lName Owner's Nam /JtUTI �K �/¢(J/J/�E,4 A%MOWS 11115 I&/A16�70 I O . n� Phone T' QQ Contractor's Name 4)U)A/FJC_S[1 Z,,96,e. License No. Phone SA,,%CE TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION'S rW'l PUMP INSTALLATION SYSTEM REPAIR / OTHER DISTANCE TO NEAREST: SEPTIC TANK ---•-----•SEWER•L•INES r- -,'DIS,POSAL-FLD: --•-------PROP: LINE--- FOUNDATION INE-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE w 1.TYPE OF-WE PROBLEM AREA CONSTRUCTION SPECIFICATIONS FJ Industrial [`Open Bottom3:.� F�Manteca Dia. of Well Excavation Lf Domestic/Private Gravel Pack Q Tracy, Dia. of Well Casing L7 11- Public E]Other, DeltaG$- Type of Casing Lj Irrigation A0prox. [] Eastern '"*�, Specifications I caions Cathodic Protection Depth `a° �� r Depth of Grout Seal Geophysical ,. . Other Type of Grout Surface Seal Installed bye ,11 a Repair Work Done E] Type of Pump H.P. State Work Done 'w.` ¢ s _►.^ I' �) Well Destruction Well Diameter Sealing,Mater'ial (top 50') ) , Depth J ., Filler Material '(Be o„50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ; (No septictank or seepage pit permitted if public sewer`is ° available within 200 feet.)'' Installation will serve: Residence,' fCoinmercial r-owOther {' i— 1 � � Number of living units: Number of ¢gdrooms q &Lot;size 1J` "E_ Character of soil to a depth of 3 ff t: L d � `" ' ' Water table depth t SEPTIC TANK [ Type/Mfg Capacity A .BD No. Compartments .� PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal f, SEWAGE SYSTEM Distance tolnearest: Well Foundation Property Line ( , DESTRUCTION C1 f LEACHING LINE No.�& Length of lines &0 L Total length/size /Ao FILTER BED E] Distance to nearest: Well Foundation Property Line f SEEPAGE PITS D6 Depth Size Number F SUMPS ❑ Distance totnearest: Well Foundation Property Line s fa, DISPOSAL PONDS F � 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. t Home owner or licensed agent's signature certifiesthe 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 workmans 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 all for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FO P ENT USE ONLY f�� _ Application Accepted by _ Area VStk 466-6781 Additional Comments: r } '� Lodi 369-3621 Pit or Grout Inspection by Ir Date t Manteca 823-7104 Final Inspection by ° Date '�ly- V Tracy 835-6385 Applicant - Return all copies'to: Environmental 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. INFO EH 13-24 REV. 10/82 .- f _G� 10/82 500 ! 14-26 - K� I .