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APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ) 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Y3_y0 y Telephone (209) 466-6781 DATE I55UED 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 Reguullations f the San Joaq in Local Health District. Job Address 1I �� +/��i Subdivision Name Owner's Nam G f^ Address �I,- U ( �. ►`�.�.Ct cr c Phone 3 `-D� License No. �° Phone ractor's Name t7 i l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLAT ON SYSTEM REPAIR OTHER f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE P5 ' G FOUNDATION 1O AGRICULTURE WELL OTHER WELL lZ�b�- PITS/SUMPS INTENDED USE TYPE OF LL PROBLEM AREA CONSTRUCTION SPECIFICATIONS adustrial U Open Bo tom ❑Manteca Dia, of Well Excavation mestic/Private [:] Gravel Pack Tracy Dia. of Well Casing Public E]Other [] Delta Type of Casing Irrigation Aprhx. g'Q Eastern} Specifications Cathodic Protecton D on p Depth of Grout Seal Geophysical F Type of Grout IC- Cj- Other Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State Work Done 0 Well Destruction U Well Diamet Sealing Material (top 50') Depth Filler Material (Below 50') [� c TYPE OF SEPTIC WORK: NEW INSTA LATION U REPAIR/,ADDITION .0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Re idence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a dept of 3 feet:. Water table depth SEPTIC TANK �j Ty /Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Ty e/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Di tante to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE LJ N . & Length of lines Total length/size FILTER BED ❑ istance to nearest: Well Foundation Property Line SEEPAGE PITS epth Size Number SUMPS j_j Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D r 1 hereby certify that I ave 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 gent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I sha I 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 must c 1 r all required inspections. omplete drawing on reverse sid Signed X Title Date: E MENT LY Stk 466-6781 Application Accepted by � Rr a " Additional Comments: 19Lodi 369-3621 Pit or Grout Inspection by Date L3 Manteca 823-7104 Final Inspection by — - Date Tracy 835-63B5 Applicant - Return all copies o: Enviro ental H alth Permit/Services 1601 E. Hazelton Ave., ,P.O. Box 2009, St k., CR 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED �RECEIVED BY DATE_ /SND.[NFO �;P 1.1 Z - ff 10/82 500 EH 13-24 REV. 10/82 14-26