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APPLICATION FOR PERMIT f SAN JOAQUii! LOCA! HEALTH DISTRICT �! 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. (P Telephone (209) 466-6781 —511 7 � 0ATE 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�f 5�9 ,�y✓y /,Z._O Subdivision Name Owner's Name . vP_ !'y11�f>Jfi�. _ Address 7 , f r Phone ;215? Contractor's Name {, License No. Phone -Y TYPE OF OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION a( PUMP INSTALLATION SYSTEM REPAIR OTHER ^•G" , DISTANCE TO NEAREST: SEPTIC TANK.{) f7' SEWER LINES DISPOSAL FLD. PROP. LINE " FOUNDATION r+ AGRICULTURE WELL OTHER 14ELL PITS/SUMPS V" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom X Manteca Dia. of Well Excavation IJ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public [j Other} ❑ Delta Type of Casing V Irrigation 1?5 ' Approx. E] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal 17 GeophysicalType of Grout Other Surface Seal Installed by � Repair Work Done L� Type of Pump H.P. State Work Done V Well Destruction U Well Diameters Sealing Material (top 50') — Depth Filler Material (Below 50')J. - TYPE OF SEPTIC WORK: NEW 1NSTALLeA{ION REPAIR/ADDITION —J (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 7 Character of soil to'a'�depth of!3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity is O No. Compartments PKG. TREATMENT PLT. [] Type/Mfg . Capacity Method of Disposal i SEWAGE SYSTEM Distance to nearest: Well p00 Foundation /p Property Line �p DESTRUCTION r �. LEACHING LINE No. & Le'gth of line Total length/size y FILTER BED Distance to nearest: Well ®o Foundation /Q Property L ne alp SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I hereby certify that 1 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ f the work far which oy any person in such manner as to become subject to workmanb compensation laws of California." k{ Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance o Ik this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." EEE The applicant must call for all required inspections. Complete drawing on reverse side. Si ned � Title: />�l�v J ` �^ Dat e: 3 - 9 �11111FORDEPARTM �/ `. � Stk 466-6781 � � R�h e Application Accepted by Area La di 369-3621 Additional Comments ' Manteca 623-7104 Pit or Grout Inspection by Date Final Inspection by Date4'0-� L7 Tracy 835-6385 09, Applicant - Return all copies to:.. Environmental Hea th Permit/Services 1601 E. Hazelton Ave., P.D. Box 20RMI St k., CA 95201 FEE BASE AMOUNT DUE RECEIVED BY DATE PERMIT NO. � INFO3— ►► L U [ 0 �108� 500 FH 13-24 REV. 10/82 14-26 II