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APPLICATION FOR PERMIT /1 SAN JOAQUIN LOCAL HEALTH DISTRICT�G r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1J 1 �• Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r^ (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. 1 Job Address �3/ �/,� ubdivisian Name Owner's Name , [i/ R,J 41,Q/s,40e& A Addres Phone Contractor's Name /1,;�, �uLL[��_ License No. /i$ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ U. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . U Open Bottom ❑Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack 0 Tracy Dia. of Well Casing . - -r 'M ❑ Public �+ ❑ Other Q Delta ,Type of Casing E_kIrrigation Approx. ❑ Eastern F-1CathodicProtection Depth Specification ., Depth of Grout Seal ❑Geophysical + , .. Type of Grout E3 Other Surface Seal.Installed by Repair Work Done.0 Type.,of--Pump .. HSP. . State Work Done Well Destruction ❑ Well Diameter' Sealing Material (top 50') Depth Filler Material (Below 50') -W _ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 3? (No septic tank or seepage pit permitted if publ.ic sewer is �•--�----=avai•iable-within-•200-feetr)— S� Installation will serve: Residence 4z Commercial Other .. S x Number of living units: Number of bedrooms �"� _ Lot size,k Character of soil to a depth of 3feet:'" " d'�jj Water table depth6� SEPTIC TANK Type/Mfg ...�.: `-" -0—Capacityr No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity ,T po sal Septic Tank Distance-to-nearest: Wel-l- Foundat on • Property Line Destruction .-E3 LEACHING LINE LJ No. & Length of lines ) ,,Total.len th/size FILTER BED l• Distance to nearest: Well 40.1;C7Foundatic2D�i 'Property Line. SEEPAGE PITS ❑ Depth Siie Number SUMPS ❑ Distance to nearest: Well ''-,iF,oundation',, :: i Property Line DISPOSAL PONDS ❑ v, 3 ', 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. �'. i Home owner or licensed agent's signature certifies the following: "I certifyithat in. the performance of thework 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: "Ilcertify that in the performance of the work- for which this permit is issued I shall employ jcompensation p y persons subject to workman's laws€-of California."" 1. € a .�. . The applicant m t all for all required inspections. Complete drawing on reverse side. s� Signed X ,�,. j ^. � - Title: / -- Date: /y "$c FORA"TM USE ONLY Application Accepted by Area a 7. -- '' ❑ Stk 466-6781 : Additional Comments: _ _ _ f Lodi 369=3621 , Pit or Grout Inspection byT Date,— Q Mant@ca 823-7104 Final Inspection by bate . '"" ^�] Tra' yy 835-6365 w, Applicant - Return all copies to: Environmental Hea ermit/Services 1601-E.--H62elton Ave:; P.O; Box 2009, Stk:, CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ' INFO _ ,t7 O r K! t EH 13-24 REV. 10/82 l ��-�! 3 -.— .- :_.__._. _ _ ._....10/82 500.. ,. .j