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APPLICATION FOR PERMIT i SAN 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 Regulations of the San Joaquin Local Health District. Job Address .R6 I'> $: 13,11y 714 /?W, Subdivision Name rY Owner's Name pf oZ_1 191gl S&ttl Address .� ✓`r� 50. Pel rygG Phone Contractor's Name .�ll1�T� / J/Jr License No. y��--�9� Phone TYPE OF WELL/PUMP WORK: NEW WELL F] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSJ, IJ Industrial U Open Bottom Manteca Dia. of Well Excavation L_1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing 17 Public F-1 Other E] Delta Type of Casing Lj Irrigation Approx. E] Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal D Geophysical Type of Grout 110ther Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') • TYPE OF SEPTIC WORK: NEW INSTALLATION X1 REPAIR/ADDITION CJ (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: SAN A DLJ Water table depth a $- i SEPTIC TANK ® Type/Mfg Qye CA 5' Capacity d O 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 % /fl0 Total length/size /00 3 t.,J FILTER BED Distance to nearest: Well 3&61 ' Foundation Property Line o? C SEEPAGE PITS F-1 Depth Size Number SUMPS F-1 Distance to nearest: Well 3-01&, Foundation Property Line DISPOSAL PONDS ❑ 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 m call for 1 required inspections. Complete drawing on reverse side. Signed X Title: Date: F DEP ENT USE ONLY Application Accepted by -- /' l ' ej, Area Q Stk 466-6781 Additional Comments: owl E] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date r ❑ 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 . _ i y EH 13-24 REV. 10/82 10/82 500 14-26