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t-. APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 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 and Regulations of the San Joaquin Local Health District. Job Address /7 �rm . � �� Subdivision Name Owner's Name l7I'Iy C�wS Address Phone Contractor's Name 1y �►�(Z('l� License No. y / Phone ?31" ;N29 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing In ❑ Public ❑Other ❑ Delta Type of Casing �f Lf Irrigation Approx. ❑ Eastern Specifications J Cathodic Protection F-1CathodicDepth of Grout Seal 1 ❑Geophysical Type of Grout V ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') T TYPE OF SEPTIC WORK: NEW INSTALLATION �� REPAIR/ADDITION ❑ (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: 1 Number of bedrooms Lot size ArP-___4 9!_ Character of soil to a depth of 3 feet: Water table depth 2 Q SEPTIC TANK rg Type/Mfg Pke-e,A s T Capacity /2C C% No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM 1—I Distance to nearest: Well 00' Foundation f O Property Line' DESTRUCTION ❑ LEACHING LINE LW No. & Length of lines 70f Total length/size Q FILTER BED ❑ Distance to nearest: Well J001 Foundation /0 Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: Well Foundation 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. 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 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 per ons subject to workman's compensation laws of California." The applicant m t call for all equire nspections. Complete drawing on reverse side. Signed X / / m Title: 1K�"hk(� Date:.. F EPARTMENT USE ONLY Application Accepted by Area �� ❑ Stk 466-67.8.1 " Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date — $y ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE1P'ERMIT NO. I-NFO V Z �*'1— h 10/82 500 EH 13-24 REV. 10/82 r 14-26