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APPLICATION FOR PERMIT SAN JOAQUiI! LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 �� ; ago P_J� n WW-Al _ ,Subdivision Name Owner's Name IL..L1AM.AJ&ajq ZX/ Address Stege Phone06--'7f0-3 Contractor's Name ;=f 0Vh 6, 14&JeA License No. #Zf 7,7i, Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT 0, DESTRUCTION U !' PUMP-INSTALLATION F-1SYSTEM —REPAIR- —OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPFCIFiCATION5' f�JIndustrial U Open Bottom. ❑ Manteca Dia, of Well Excavation U Domestic/Private F_1 Gravel Pack E] Tracy Dia. of Well Casing Public J Other r Delta f - — — " " t Type of Casing - Irrigation asing -Irrigation Approx. Eastern Specifications [�Cathvdic Protection Depth # ou Seal 71 Geophysical Depth of &Grout E Type of Grout t U 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 IJ (No septic tank or,seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence /� CommercialOther Number of living units: Number of bedrooms —_�. Lot size X-47F Character of soil ��Type/Mfg epth of 3 feet: Water table depth SEPTIC TANK If-e- Capacity`A kiNo. Compartments-00 a- PKG. TREATMENT PLT. F] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation __ _ Property Line zhr _ ; DESTRUCTION LEACHING LINE No. & Length of lines 7- — Total length/size 7Q Z FILTER SED �r ` Distance to nearest; Well Abp s Foundation Property Line i SEEPAGE PITS Depth I- 1 Size 2:34- Number SUMPS �� # Distance to nearest: Well ]_ Foundation ,(J�tE 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. + 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 11 required in pections. Complete dr wing on reverse side. Signed X Title: Date: FOR R USE ONLY � Application Accepted by aIY�.lp. NT Area �� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by 7 Date �/e�3 Manteca 823-7104 Final Inspection by w Date _/ j L7 Tracy 835-6385 Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ,q✓ � 403 EH 13-24 REV. 10/82 , 00/82 50C 14-26