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APPLICATION FOR PERMIT SAN JOAQGiN 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 f the San Joaquin Local Health District. Job Address 941_3 Subdivision Name Owner's Name ^^ ,, Addre76 . - Phone Contractor's me y > (I6i ori License No. 1 71�^ Phone 33533 ©� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-] DESTRUCTION W 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 IJ Industrial U Open Bottom F-�Manteca Dia. of Well Excavation U Domestic/Private 7 Gravel Pack F-1 Tracy Dia. of Well Casing Public F-jOther Delta Type of Casing LjIrrigation Approx. Eastern Specifications Cathodic Protection Depth F-11atroecDepth of Grout Seal 0 Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') r ,\ TYPE OF SEPTIC WORK: NEW INSTALLATION �EPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is V" available within 200 feet.) p Installation will serve: Residence 1ol� Commercial Other V Number of living units: 4-- Number of bedrooms 3 Lot size >Q, AAg,, ! Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [ Type/Mfg r�_ p '� Capacity ��(� No. Compartments 7 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 040, Foundation _ Property Line DESTRUCTION len LEACHING LINE �� Total length/size No. & Length of lines ,�=fS p __ 9 7 �� /r/VV — FILTER BED Distance to nearest: Well — Foundation 3 Q Property Line SEEPAGE PITS Depth Size Number SUMPS 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-contr sting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall ploy p rsons subject to workman's compensation laws of California." The applican s call or a r d inspections. Complete drawing on reverse side. / r� Signed r Title i(, Date: r/ ori OR DEPARTM plication Accepted by Area ❑ Stk 466-6781 Additional Comments j� r Lodi 369-3621 Pit or Grout InspeA on by Date Manteca 823-7104 Final Inspection by Date � -�� ❑ Tracy 835-6385 Applicant - Return all c ie o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE q PERMIT NO. INFO 10/82 500 EH 13-24 REV. 10/82 14-26