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n J F APPLICATION FOR PERP',!_ SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, �� r1 0 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 in Local Health District. Jab Address 2$_Z..B �N i� —{P Jvac Smart Subdivision.Name �!✓'G7�j r Owner's Name 00C G12 _QJ I.LA tq&� Address SA"e Phone j—��en Contractor's Name License No. 2—S4�Q,'3 Phone 46&,-:Na07 1 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR L7 OTHER 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 SPECIFICATIONS Industrial U Open Bottom [] Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of Well Casing 0 Public Other Delta Irrigation I- Type of Casing ation V g ° Approx. D Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout k Other ftl Surface Seal Installed by Repair Work Done G Type of Pump H.P. State Work Done Well Destruction U Well Diameter 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 60 �► available within 200 feet.) Installation will serve: Residence X Commercial _ Other Number of living units: _/_ Number of bedrooms _�3 Lot size Water table depth f (} Character of sail to a depth of 3 feet: � r�>h✓� P SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments " t PKG. TREATMENT PLT. Type/Mfg ' Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line �l DESTRUCTION t� LEACHING LINE XL No. & Length of lines /+—��Q� Total length/size Zd , FILTER BED Distance to nearest: Well +/450." Foundation Property Line y . SEEPAGE PITS Depth Size 'OV Number r SUMPS Distance to nearest: Well A0 Foundations Property Line DISPOSAL PONDS C� 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 wvrkmant compensation laws of California." Contractor's hi ing or sub-contracting signature certifies the'followina: "I certify that in the performance of the work for which this permit is ssued, I sh 1 employ ersons subject to workman's compensation laws of California." The appli n call f all re red in pections. Comple dra n reverse side. Signed X Title: Date: 7: Fb E ART T USE ONLY Application Accepted by Area �� Stk 66- Additional Comments: Lodi 369-3621. Pit or Grout Inspection by e Date U Manteca 823-7104 Final Inspection by /'' - Date ❑ Tracy 835-6385 Applicant "Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASF AMOUNT DUE AMOUNT .REMITTED: RECEIVED BY DATE PERMIT NO. INFO ys ys T No -z * V EH 13-24 REV. 10/82 w 10/82 500 14-26 y