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1 APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S73- 5?5-0 Telephone (209) 466-6781 7 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED g (� 1 (Complete in Triplicate) l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ~1 described. This applicat ior is made in compliance with San ,oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules�and�Regulations o the San Joaquin Local Health District. `1 3 Job Address = 7�y' S the Subdivision Name 7- Owner's Owner's Name Address Phone Contractor's Name"i__W� License No. , "'<r 43— Phone V 9� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ij,h e Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �,_ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE r` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 Type of Casing ❑ Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical } 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 Filler Material (Below 50') TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑! REPAIR/ADDITION �No septic tank or seepage pit permitted if public sewer is ~� available within 200 feet.) Installation will serve: Residence Commercial _ Other t I{umber of living units: Number of bedrooms .P Lot size 'v S i U7Ao� rr?c La3Mr Character of soil to a depth of 3 feet: i � j Water table depth „ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal J SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE Nod & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE:PITS D Depth Size Number SUMPSDistance to nearest: Well Foundation Property Line DISPOSAL 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. w 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,.,l 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 fallowing: "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 app'l, an m st call fo 11 required inspections. Complete dra g on reverse side. Signed X v Title: Date: F 'D PARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: ❑ Lodi 364-3621 Pit or Grout Inspection by Date Le_ nteca 823-7104 Final Inspection by Date .3 ❑ Tracy 835-6385 Applicant - Return all copies CIP7 9vironmentaI Health Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NC. INFO Q_ � j EH 13-24 REV. 10/82 �J 10/82 500 1'\ 14-26