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J # .--APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.IS - 4 O Telephone (209) 466-6781 GATE ISSUED�3 PERMIT E7(PIRES 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 SO 6 ", ,?.9/Y7A Subdivision Name Owner's Name A-6 C- Address Phone S•3 1>7y977 Contractor's Name . s s � SN License No. !F6- 5�'${, Phone ✓ate'`!��'� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom 0 Manteca Dia. of Well Excavation 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta � irrigation Type of Casing U 9 Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications Depth of Grout seal ❑Geophysical Type of Grout U Other Surface Seal Installed by a Repair Work Done ❑ Type of Pump ° H.P. State Work Done Well Destruction U Well Diameter '° Sealing Material (top SO-) .) Depth Filler Material (Below 50') } TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION tR (No septic tank or seepage pit permitted if public sewer is iavailable within 200 feet.) Installation will serve: Residence i- Commercial _ Other Number of living units: _ 'Number of bedrooms :2- Lot size ! Ac->-V C4 Character of soil to a depth of 3 feet: _ de3y OA _ Water table depth SEPTIC TANK ❑ Type/Mfg fyG. �,�s y- - Capacity J ZGib � No. Compartments X. PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well .6;-47 Foundation 3a i Property Line '0 ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑[ Distance to nearest: Well I Foundation yo Property Line 15:-.- SEEPAGE PITS ❑ Depth Size Number _ SUMPS - IJ Distance 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 theper_formance of-the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman t 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 ust call f r all required inspections. Complete drawing on reverse side. 41 Signed X_ 5;ry T Title: Date: :5 -/A -,r-X r-y Application Accepted by _ FO�PARTMENT USE ONLY Area ® ( ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmen ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE 'AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _6aq3- qbq a EH 13-24 REV. 10/82 10/82 500 i 14-26 ' -