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F h APPLICATION FO.RidERMIT SAN JOAQL'iI, LOCALFHEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 20 (40 ' Telephone (209) 466-6781 g DATE ISSUED 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (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 337 4 64 -C! d -re CA Subdivision Name a Owner's Name ,�{G�f$t2]9 6IS Address S MAP Phone$Z3-�( _ Contractor's Name License No, SIG GL 3 Phone + h 1 � TYPE OF WELL/PUMP WORK: NEW WELL ❑ ;WEL-L -REPIFACEMENT ❑ DESTRUCTION [f PUMP INSTALLATION` E3) SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK AEWER;LINES DISPOSAL FLD. PROP. LINE r FOUNDATION '+ i AGRICULTURE WELL _ `'OTHER WELL -PITS/SUMPS INTENDED-USE �r TY2Ef.OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS tir 4 F-1Industrial '� t U 0pe'n1Botton' ❑-Manteca Dia. of Well Excavation LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public �jOther ❑ Delta y Type of Casing U Irrigation -- "Approx.- "❑-Eastern Specifications ❑ Cathodic Protection !Depth - t�---+_- y Depth of Grout-Seal ❑Geophysical ` Type- 7 } `s o'f,Gr`aut «��rT ! ❑-Otherx surface Seal Installed bye I Repair Work Done ❑ Type of Pump H.P. State Work Done n� Well Destruction ❑ Well Oiameter_ `%Sealing Material (top 501) - ..� Depth -Filler-Material-(-Below 501 I r- ! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION N?� (No septic tank or seepage pit.permitted-,Iif public sewer is I ! available within-200 feet.) Installation will serve: Residence Commercial Other Number of living units ,._ ? Numbersof bedroomsLot size `� y Character of soil to-; depth of;3rfeefy:� '_ Water table depth It .- SEPTIC TANK . ❑ Type/Mfg 1Capacit{� � Na. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity P SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line i DESTRUCTION ❑ f - i i, LEACHING LINE X--,4 No. & Length of lines /f' Total length/size ftt/SID� Ak,' LO t � FILTER BED Distance to nearest:*"'WelI � _ Foundation s Property,Line �} SEEPAGE PITS [j Depth Y7;! Number SUMPS U Distance -fo nearest: Well Foundation, ]Q! Property Line DISPOSAL PONDS El I hereby .certify- hat- I have prepared this application and that the work- ill be done in accordance with San Joaquin county ordinances,- stjZ laws.,,and rules and regulations of-the San Joaquin Local Health District." Home owner or licensed a07nt's.siignature certifies the following. "I certify'that7in the performance of the work for which this permit is issued, 'I shall not.em ploy any- person in such manner as to become subject to 'vrorkman c6mpersation laws of California."i Contractor's hiring or sub-contracting ignature certifies the following: "I-certify thatL,in the-performance of the work for which this permit-i issued, I shall employ rsons sisEj'eef'to workman's-compensation law's�of-Cal;iforn a." The applican all fo all req ed in ection,sT"Comple n reverse side. c_ Signed X Title: TDate: U FOR DEPARTMENT USE ONLY �f Application Accepted by Area ❑ 5tk ^0.66-6781 Additional Comments: ❑ Lodi 1369-3621 Pit or Grout Inspection by Date - ❑ Manteca 8237104 Final Inspection by F Date ❑ Tracy 835-6385 - - - Applicant - Return all copies to: Environmental Health Permit/5eryices •1601 E. Hazelt nye., P.O,{BoxN2009,St k., CA 95201 Tr iiw- FEE--- -BASES AMOUNT..-.DUE � AMOUNT REMITTED . � �RECEIVES 8Y DATE � PERMIT N0. -� INFO 10/82 500 FH 13-24 -REV. 10/82 '� 14-26 .-