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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 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. 186? for well/pump and the Rules a d Regulations of�thhe San Joaquin Local Health District. Job Address I � V % N f,V � Subdivision Name Owner's Name 'iW-►, S'es -PC rT' Address r1V Phone Contractor's Name s o "C 'C�,, License No. Phone ell` ) TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ _ DESTRUCTION ❑ # PUMP INSTALLATION ❑ SYSTEM'REPAIR' OTHER ❑ '' -� DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP..*LINE (FOUNDATION AGRICULTURE WELL OTHER WELL "PITS/SUMPS INTENDED USE V TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t:] Industrial ❑ Open Bottom EManteca Dia. of Well Excavation (❑ Domestic/Private ❑ Gravel Pack ❑ Tracy v Dia. of Well Casing ❑ Public -N F71 Other ❑ Del to� - ' ,) Lype;,of Casing{ 0 Irrigation Approx. ❑ Eastern tr4 kw Specifications r Cathodic Protection Depth 4 Depth of Grout Seal { ❑ Geophysical s I Type of ,Gr�ou't,' f [7j Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done g Well Destruction ❑ Well Diameter Sealing Material. ,(top 50') _4 3 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is -,y : available within 200 feet.) Installation will serve: Retidence Commercial Other Number of living units: Number of bedrooms,s !) 'S .Lot, size.}Y• Character of soil to a deph of t 3 feet: Water tdble• depth /� rr : SEPTIC TANK T! Type/Mfg p C Capacity %�tDO No. Compartments, ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of U1 rposal 1 SEWAGE SY.S.T.EMDistance to nearest: Well Foundation Property, Line" DESTRUCTION LEACHING iPNE ) �No. & Length of lines £� Q ) Total length/size 1\d /YL,c� { FILTER BEDS j "❑ Distance to nearest: Well Foundation Property Linef SEEPAW PITS Depth Size Number �. { -� �— {} SUMPS Distance to nearest: Well Fou" ndation /�oProperty Line �p 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�'f6llowing: "I certify thatin:the.performance of the work for which this y' permit is issued, 'I shall not employ any person in such manner as to become subjecttoworkman compensation laws flf California." Contractor's hiring or sub -contrasting signature certifies the`followngi; "I •cert ify that in the performance of the work for which this permit is is ued, I shall employ person subjec't'°to workman's compensation laws of California." I The applicant 11 for alI q 'red inspections. Complete dr wing verse side. � %J a Date: I Signed X (./: --••'-.—•--Tithe: - — FOR DEPART NL r Application Accepted b Area or" ❑ Stk 456-6781 3� ❑ Lodi 369-3621 Additional Corn men jGl� Pit or Grout Insp ction by Date . WManteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to:. Environment Health Permit/Services 1601 E. Hazelton Ave., r P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RE�CE�IVVEED BY DATE PERMIT NO. INFO � [ ✓ �� " Y-, �i D-� � b � t 3 % 10/82 500 EH 13-24 REV. 10/82 14-26 IN co