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i �- APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO.'j'3 — $ $3 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 rd Regulations of he San Joaquin�1]oc 1 Health District. -} Job Address �} Y�• a Cllr {�� ` Subdivision Name .-. LO Z Owner's Name G Address ?a yt/e*< C_ :t,— Phonea� Contractor's Name D24,Aj License No. B --4t& (24- Phone TYPE OF WELL/PUMP WORK: NEW;WELL E] WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION F AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE Industrial jJ Domestic/Private Public V Irrigation Cathodic'Protection ` Geophysical U Other TYPE OF WELL PROBLEM AREA U Open_. Bottom [] Manteca Gravel Pack ❑ Tracy D Other 0 .- ❑ Delta Approx, Eastern Repair Work Done ❑ Type of Pump Well Destruction IJ Well Diameter Depth CONSTRUCTION SPECIFICATIONS Dia, of Well Excavation Dia. of Well Casing Type of.Casing'7 Specifications Depth of Grout Seal Type of Grout Surface Seal Installed by H.P. State Work Done Sealing Material (top 50') Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION jJ (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence 2< Commercial,.._ Other Number of living units: I Number of bedrooms Lot size I 5 �/ �,4P Character of soil to a depth of `3 feet riVi Water table depth SEPTIC TANK ❑ Type/Mfg %- L 4f ©vtk- • Capacity i ?n2a _ No. Compartments PKG. TREATMENT PLT. Type/Mfg �� " Capacity Method of Disposal SEWAGE SYSTEM o Distance to_nearesf"T Well % Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines' �� Total—length/size O 17 FILTER BED Distance -to nearest: Well Foundation PropertyLine SEEPAGE PITS Depth { k r r _:m- Size l Number f SUMPS U 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 persons subject.to workman's compensation laws of California." The appy ust call for llr red i specti s. Complete' drawing on reverse side. {g� Signed X Title: 09C47 ��. ,6 DEPARTMENT USE ONLY Application Accepted by ��(� Area/� ? Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Ma ca 823-7104 Final Inspection by �H-lth Date LTracyTracy 835-6385 Applicant - Return all copies to:Environm l Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO kIAS�E,7 SS. o l7 EH 13-24 REV. 10/82 14-26 10/82 500