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APPLICATION FOR PERM;T SAN JOAQUiN LOCAL HEALTH DISTRICT 4 ]� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, Telephone (209) 466-6781 GATE ISSUED [13 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 AddressYr 1:Z,6j,7 <� y,4N All.- / Subdivision Name Owner's Name Address� ygs S. Y ��,� Q,yJi,�gAg4one Contractor's Name License N0.��7�[/y - Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER L DISTANCE TO NEAREST: SEPTIC TANK �4:�o 1t SEWER LINES < r± DISPOSAL FLD."d 4 PROP. LINE ,Q fi �y FOUNDATION /p '4 AGRICULTURE WELL l OTHER WELL r— PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AR A CONSTRUCTION SPECIFICATIONS tai Open Bottom Monte Dia. of Well Excavation /- ----- - __ U Domestic/Private F]Gravel Pack L Tr Dia. of Well Casing 1:2 L7 Publis Ej Other ❑ lto Irrigation ( Type of Casing uJ ,C ,�� t V g Approx. Eastern Specifications /' o4_ Cathodic Protection Depth ��r] `f 1-1 Depth of Grout Seal ~ Geophysical Type of Grout e, f A2�2,9,t� FV Other LIN Surface Seal Installed by n1 }&,C 0L Repair Work Done FJ Type of Pump H.P. State Work Done Well Destruction L Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') S _` TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION Q (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: Number of bedrooms _ Lot size Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK L Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line a DESTRUCTION P LEACHING LINE L No. & Length of lines Total length/size 3 FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L Distance to nearest: Well Foundation Property Line 01SPOSAL 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 s.gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat emplo rsons subject to workman's compensation laws of California." The applic 11 for re i e pections. Complete drawing on re erse side. 3 0 Signed X Title: Date: F9Q DEPARTMENT USE ONLY Application Application Accepted by Area 40!P Stk 466-67$1 Additional Comments: C Lodi 369-3621 e Pit or Grout Inspection by ate ^� Manteca 823-7104 Final Inspection by U Date Tracy 835-6385 Applicant - Return all copies to: Enviro al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE�4_ PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 1