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w APPLICATION FOR PERMIT SAN JOAQUIN 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 Ito"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 )oaquin Lo ealth District. Job Address :!C3, A S.I.Asc4" 4 AJ: Subdivision Name . Owner's Name 5 A V 0dress a4ONj H 1- A) hone Contractor's Name t� Jr34�se No. J Phone 7-4 TYPE OF WELL/PUMP WORK: NEW WELL p-0, WELL REPLACEMENT DESTRUCTION PUMP INSTALLAeTION FP SYSTEM REPAIR U OTHER U DISTANCE TO NEAREST: SEPTIC TANK oAgtA SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T I Industrial +@pen Bottom Manteca Dia. of Well Excavation V }t<mestic/Private Gravel Pack [ Tracy Dia. of Well Casing --�` 17 Public Other Delta Type of Casing `— V�- rigation Approx. D Eastern Depth Specifications Cathodic Protection . Depth of Grout Seal � Geophysical —��-- p Type of Grout LJ Other Surface Seal Installed by C� PIlV Repair Work Done ❑ Type of PumpH.P. State Work Done Well Destruction U well Diameter T 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 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM :Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines- Total length/size FILTER BED Distance to nearest: Well Foundation Property Line t SEEPAGE PITS Depth Size Number SUMPS IJ ::.Di stance 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. 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 workmanK 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 appl1 all fo 1 required pections. Complete drawing on reverse side. sy Signed X Title: OateQ V FOR XTM T USE ONLY y Application Accepted by � AreaO�W Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by. d !� Ll Manteca 823-7104 i Final Inspection by Date -'' ❑ Tracy 835-b385 Applicant - Return all copies t ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5t k., CA 95201 FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. Ca -0 7 - EH 13-24 REV. 10/82 ]�/l,r �r/Af �f 0 82 500 �- 14-26 I I r Y '�-�