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APPLICATION FOR PERMIT: . SAN JOAQL'i" LOCAL riE-,LTH DISTRICT s• 1601• E. HAZELTON AVE., STOCKTON, CA PERMIT NO. glA g Telephone (209) 466-5781 DATE ISSUEDL�4 -. PERMIT EXPIRES 1-YEAR FROM DATE ISSUED a (Complete in Triplicate) S� 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 RulesandRegulations of.the San Joaquin Local Health District. Job Address /J �Z-� �/"e� ird L cJ, "Subdivisian Name Owner's Name b H e y. Address /,j,Y2 S �,ppa ►t d Odr1 Phone Z 7 3 . Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal ❑Geophysical F Type of Grout ❑Other Surface Seal Installed by Repair Work Hone ❑ Type of Pump H.P. StateLWork Done q� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ['n1 TYPE- OF SEPTIC WORK: NEW INSTALLATION U. REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is �C h available within 200 feet.) Installation will serve: Residence Commercial _ Other J� �Q Number of living units:y Number of bedrooms �� Character of soil toa depth of 3 feet: 3' Water table depth SEPTIC TANK [j`� `Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal O 4 SEWAGE SYSTEM I IDistaoce to nearest:. Well.. �. Foundation-._ Property Line . DESTRUCTION C] LEACHING LINE ❑ No. & Length of lines Total length/size FILTER•_8ED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number J ✓ - SUMPS ❑ Distance to nearest: Well Foundation t 6 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. 1 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 A-to-become subject to wdrkmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the h1 lowing:"'I+certify thattin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of-.California." The applica ust all for all required inspections. .TComplete drawing on reverse side. ry Signed X Title: �` 'x Date: Aoil 7 y FOR DEPARTMENT USE ONL y Application Accepted by ( Area �>'� ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ` ❑ Manteca 823-7104 Final Inspection by Date (� Tracy 635-6385 Applicant - Return all copies to: Environmental He th it/ 1601 E. Hazelton, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED F RECEIVED BY DATE PERMIT NO. INFO , 10/82 500 EH 13-24 REV. 10/82 14-26