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e ' 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 Subdivision Name Owner's Name T 0; LL 0.*P,v RCgI1s7' Address Sri+90 Phone € Contractor's !Name S o y ` License No. Y $ Phone 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'S AGRICULTURE'WErL `" --OTHER•WELL•— _ -PITS/SUMPS <' a 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_ ❑ Public ❑ Other ❑Delta i Type of Casing Irrigation A ❑Cathodic Protection Deprox. Eastern th ❑ Specifications Depth of Grout,Seal ❑Geophysical ',, "'�. i ❑ � ; � Type of Grout 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 4 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION' j REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 1� 1 available within 200 feet.) Installation will serve: Residence - Commercial iOther '. Number of living units: Zj Number of bedrooms Lot size .5 4 N/� Character of soil to a depth,of 3 feet: SAk9 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance--to-nearest:F WeI1 �f/� Founda1tion /O!� Property Line ✓r 1 J\ DESTRUCTION ❑ ~ �7'� LEACHING LINE ❑ No. & Length of lines Total length/size 1 F •� FILTER BED �❑/ Distance to'nearest: Well Foundation...- Q_ Property Line �1 ` SEEPAGE PITS [] Depth Size Number' SUMPS L 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . f 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 Lgcal Health District. , Y."• -- 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 applicant mus all for l required inspections. Complete drawan on reverse side. Signed X Title: ��'=! `� r Date: *-.7y-8t r FOR P M NT USE ONLY _ f t _. ,Application Accepted.,by' 4 - .Area /. -- _ — - ❑ Stk- - 466-6781 Additional Comments: o -s t ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 7 ❑ Tracy 835-6385 Applicant - Return all copies-'to: Environ nal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 w 14-26 _