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APPLICATION FOR,PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT f� 1601 E. HAZELTON AVE., STOCKTON, CA- PERMIT NO. V� Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES i 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 anegulations of the San Joaquin Local Health Distri�c)t. Job Address 1,® 1415 /�(/ � F �.►�� f SubkAW . _77,0_4 T_ M Owner's NameAddress L Phone i Contractor's NameT; J/ i12 cense No. �� i _ Phone ,'�;�rT I TYPE OF WELL/PUMP WORK: NEW WELL , WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ _ DISTANCE TO NEAREST.: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'Y00 PROP. LINE r. FOUNDATION � A AGRICULTURE WELL OTHER WELL PIT$/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia, of Well- Excavation 1-2 Domestic/Private ,Gravel Pack 19�Tracy Dia. of Well Casing �Q _ Public FOther [] Delta Type of Casing Li Irrigation Approx. [] Eastern I [Cathodic Protection Depth Specifications E24M Depth of Grout Seal &AMN ( ' Geophysical Type of Grout,(/per _ _ _ 1 Other may_ .SurfacetSea-l�Insta7led by I Repair Work Done FJ Type of Pump H.P. StateWork Done ` Well Destruction ❑ Well Diameter Sealing Material-.(top 50' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ CoMM6`rcial _ Other Number of: living units: Number O Vedrooms 'Lot-size Character'of soil to.a depth of 3 feet. Water table depth SEPTIC TANK# T e/Mf Capacity No. Compartments I!I F � YP 9 � I PKG. TREATMENT PLT. Type/Mfg; Capacity Method of Disposal .• ";z . SEWAGE SYSTEM 1 $istan a to nearest: Well Foundatibn'4'-`' Property Line 's DESTRUCTION `,� ► LEACHING*LINE U No. & Length of lines Total length/size FILTER BED ❑ 6i ance to •nearest: Well Foundation Property Line SEEPAGE PITS "D pt Size Number f SUMPS l—� Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS I hereby certify that I have prepared,thi,s application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sha�1 employ persons subject to workman's compensation laws of"California." The applicant mu$t c 11 for/al1'req 'red inspections. Complete drawing on r er si N Signed X / fr' Title: rr(�� Date: FOR ' EPART NT USE ONLY ., Application Accepted by J ry y � Area Q 4Stk 4fi6-6781 Additional Comments: —T— Lodi 369-3621 Pit o' Graut nspection by Date Manteca 823-7104 x Final Inspection by Date ` �} 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 45 S 9 $o EH 13-24 REV. 10/82 10/82 500 14-26