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APPLICATION FOR PERMIT i r SAN JOAQUiN LOCAL H;ALT�i DISTRICT 1 r ` �� 1501 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. (Q Telephone (209) 466-6781 DATE ISSUED 7 J�- 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 Z-I/ BP— Subdivision Name Owner's Name , / /p J2GAJ 1�7'�!L Address =90"LE Phone -71 Contractor's Name^ /�Lp (,�JQrj� License No. Phone *r4�S 397E rr�', LIQ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION - i PUMP INSTALLATION (] SYSTEM REPAIR L OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom C1Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing 0 Public F-1 Other Delta Type of Casing Li Irrigation Approx. E] Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout U 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') Q TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LyJ (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: l Number of bedrooms 2r, Lot size '7, X]'30 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Z Type/Mfg — Capacity I 7,q�,V No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation iv./ Property Line '7 DESTRUCTION LEACHING LINE No. & Length of lines 2- ~Z f Total length/sizeJ V , x Z FILTER BED Distance to nearest: Well Foundation Z t� Property Line SEEPAGE PITS [Fill' Depth _ '� �� Size 3 3 [I Number SUMPS Ll Distance to nearest: Well Found tion 7O` Property Line DISPOSAL PONDS ED ey L .. IVA 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 applicant must call for all required ins�pe ions. Complete drawing on reverse side. Signed X� � �t�,�� (/y7I'�. ---- Title: Date: 7-12. -03 EPARTMENT USE ONLY Application Accepted by Area + - Stk 466-6781 Additional Comments: E] Lodi ' 369-3521 Pit or Grout Inspection by Date 7` 2 —e3 F] Manteca 8234104 Final Inspection by Date -,A- Z5 —_53 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �7 DATE PERMIT NO, INFO � L � 6f-76 I EH 13-24 REV. 10/82 10/82 500 14-2fi