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Pr APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT U S ^ L "` 2J( � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. - � Telephone (209) 466-6781 DATE 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 a ulati s of the San Joaquin Local Health District. Job Address 50 1 f iFri /'20 5ubdivision Name Owner's Name /Y0121- /u L 6 Address Phone Contractor's Name /Ih License No. y��/49 Phone � 6SP TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ I Ir d ; L PROP. LINE DISTANCE TO NEAREST: SEPTIC--TANK '� S _ DiS.P_05AL FOUNDATION AGRICULTURE WELL' ;L o." OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom 4 ❑ Manteca Dia-of-We9H-fxcavation►-�-*s-- ❑ Domestic/Private ❑Gravel Pack ri❑ Tracy Dia of Well Casing # ) Public ^ Other r DeltaType _❑ of Casing Irrigation Approx. [❑ Eastern Specifications Cathodic Pr6teii6n depth i Depth-of-Grout-Seal ❑Geophysical Type of Grout ❑Othe� l Surface Seal Installed by Repair Work-Done-G Type-of-Pump'. ;t N.P. State Work Done Well Destruction ❑ Well Diameter ? Sealing Material (top 50') - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION (No Septic tank or seepage pit .permitted if public sewer,is i t! 1 - a . F ^� - ,available within 200-feet:)` Installation will serve: Residence Commercial 3othe' I �eS Number of living units: �_ Number of bedrooms Lot size y ? Character of soil to a depth of 3 feet: . I # Water table depth 1, ---J"'"'""' Capacity--L7 No. Compartments SEPTIC TANK Type/Mfg s Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity _ � .,_, Foundation , Property Line SEWAGE SYSTEM Distance to nearest: Wel l ._�— DESTRUCTION Cl 1 O LEACHING LINE -Length-of_Jines '/ i Total length/size Property Line FILTER BED fir❑ Distance to nearestW�ell Foundation _ F SEEPAGE.PITS 71 Depth 5iie 4 Number 1 Y i SUMPS < Y DISPOSAL PONDS Q u j I hereby certify that I have prepared this application and that the work will be donerif-atcordance 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 certify that in the performance of the woxkfor which this permit .is issued, I shall not employ any person in such manner as to become subject to workmar� compensation laws of California." i 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 perso s subject to workman's compensation laws of California." The,applican ;,l for all r uiredi pections. Complete drawing'67n r�v�rs'e'si'de ""r /2` ^93 4r 7--r� y7itle: �w�ek Date: Sigged X FORDEPARTMENT,�SEDNLY Area ❑ Stk 466-6781 1 Application Accepted by ❑ Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection by Date ❑ racy Date T 835-6385 Final Inspection by 'r, t Applicant - Return all copies o: . Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, St k_, CA 95241 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO:k ,. ..,� INFO T -� v). ._�_a g.3_ ..3�L 3'LL 10/82 500 1 EH 13-24 REV. 182—. 14-26