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F_ APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT S. 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 workherein 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 ' �wy a C Subdivision Name Owner's Name e Address 7 Phone - ,? /� E �-- QIZtI S ..1��f�,._, L� Contractor's Name � License No. i q Phone - TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION [7j- PUMP-INSTALLATION- ❑ SYSTEM REPAIR ❑ OTHER E] E .� <SWR LINES, DISPOSAL DISPOSAL FLD. QDISTANCE"TO NEAREST: SEPTIC TANK 1p l-1 PROP. LINE _ FOUNDATION ZV AGRICULTURE WELL SO !-¢ OTHER WELL -T- - PITS/SUMPS INTENDED USE TYPE OF WELL 'ROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial ❑Open Bottom D.Manteca Dia, of Well Excavation % Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing Public Other ❑ De a Type of Casing Irrigation LI 5 ` Approx. ❑ East n Cs Specifications r�J-A cmc--—f1* 0 Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout C L xe F-At t` ` 17 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 U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is r available within 200 feet.) 66 Commercial Installation will serve: Residence l Other Number of living units: Number of bedrooms Lot size r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (�1 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 7-1 No. & Length of lines Total length/size FILTER BEDS ❑ Distance to nearest: Well Foundation Property Line SEEPAGE.PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ +� ° tftsjt 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 pers in such manner as to become subject to-workman§ compensation laws of California." Contractor's hiring or sub-contracting sign a -following: "I certify that in the performance of the work for which this permit is issued, I ll ploy p subject to workman's tompensation.laws of California:" Thea ii t st 1] r requi spections. Complete drawing on reverse side. r. igned X Title: '-~ Dater OR A NT USE ONLY - Application Accepted by Area ❑ Stk ,466-6781 Additional Comments: Y. ❑ Lodi 369-362.1 Pit or Grout Inspection by �[, Date 14.� S^ Z.. Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO P3 EH 13-24 REV, 10/82 10/B2 '500 14-26 .r