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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 ^�g3 DATE ISSUED 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �/(f1eT (Complete in Triplicate) � Application is hereby made b the San Jlooaaq'uin Local Health District for a permit to construct and/or install the work herein described. This applicat( is made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump C and the Rules and Re�l�.ons of the San Local Heal Districtd 14 , rj//y� , r G Sob Address t ivision Name C` �/ Owner's Name [ (7 gddress P [] ©,4 K Phone Contractor's Name {JLicense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC,aTANK _ SEWER LINES " �� DISPOSAL FLO. PROP. LINE, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE" 4TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS JIiI Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation i ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑`Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications Depth❑ Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by Q ` Repair Work Done G Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION X. (Na septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercials Other Number of living units: Number of bedrooms !d Lot size Water table depth Q Character of soi. to a depth of 3 feet: S 4, SEPTIC TANNEW51, t Type/Mfg O D f` Capacity No. Compartments PKG. TREATMENT PLT ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ 1..; 1] aQ Total length/size (Jt11AP� LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance-to.nearest: Well Foundation Property Line jSEEPAGE PITS ❑j Depth Size F+k -Number SUMPS ❑ Distance to nearest: Well 16, Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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. III'F 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, 1 shall not employ any person in such manner as to become subject to workmanb compensation laws of California." t 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 subje to workman's compensation laws of California." The applicant for 1 re it ns. Complete drawing on reverse side. Signed X Title: Date: i N FO NT USE ONLY /q/ ❑ Stk 466-6781 Application Accepted byArea AdditionallComments: w ❑ Lodi 3&9-3621 Pit or Grout Inspectio Date ��Q Manteca 823-7104 Final Inspection by 04 Date ��yy ❑`Tracy 835-6385 Applicant - Return all copies to: Environ ental Health Permit/Services 1601 E. Hazelton AG e., P.O. Box 2009, Stk., CA 95201 I ` FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. —(c6 10/82 500 EH 13-24 REV. 10/82 14-26 I d