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' APPLICATION FOR PERMIT SAN JOAQUiN LOCA! HEALTH DISTRICT � f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. y Telephone (209) 466-6781. DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED --7-�-"Y- LL 61 q �h (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 Addressr�Y�'� l Subdivision Name Owner's Name Address Phone3�' Contractor's Name `- License No, phone 52A �'�- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION i PUMP INSTALLATION ❑ SYSTEM REPAIR; ❑ t OTHER DhSTANCE TO NEAREST: SEPTIC TANK'S— ""5EWER-LINES i t DISPOSAL FL'D'--' PROP::- 'INE— ' Y FOUNDATION AGRICULTURE WELL' - -CTHER-WELL" `''°-" —PITS/SUMPS' k INTENDED USE € I I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C, *❑) Domestic/Private Graved Pack ❑ Tracy ♦ Dia. of Well Casing Other Public❑ Publi❑ r ❑ Delta , Type of Casing s t irrigation �"Approx"-^� ❑Eastern y- �- ----rte LA 11 Cathodic Protection Depth °� Specifications �.�.. `i. Depth .of.-Grout.Sea,l., ❑Geophysical Type of Grout t kf Other ;.a...�. ,;��,. I i.R.s w�- ti�Surfaee�5ea1 Installed by Repair WgrkkD one ❑ LType of Pump H.P. State Work Done � WeIIT➢estruciomU�Well Diameterl Sealing Material (top 5O') ;:►; � 'Depth Filler Material (Below 50'} ``•' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E (No'septic tankfor seepage=,pit permitted if public sewer is n ��ava•ilable within 200,.feet.) f ' Installation will serve: Residents Commercial Other h ` Number of living units: ) Number of bedrooms �� Lot.size (j § Character of soil to a depth of 3 feet: AA' Water table depth._ SEPTIC TANK !; V� Type/Mfg - . ;- t. C a n ty __ No. Compartments; PKG. TREATMENT PLT. ❑ Type/MfgCapacity Method of Disposal. :• } SEWAGE SYSTEM Distance to nearest: Well (,rjj ��Foundation F 7- Property.Line ; 1 DESTRUCTION L7 �' "'�"`'"��.�" LEACHING LINE q No. & Length of'14neS--4jg Total length/size FILTER BED ❑ y+ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth -� Size Number_. #.SUMPS ❑ Distance to nearest: Well Foundation PropertyaLine I DISPOSAL PONDS ❑I } j ,�..,..._.__..rte--._.+-,-- -------T� #i 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. ► , I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this I permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation •laws of'California."+ Contractor's hiring or sub-contracting signature certifies the fallowing: "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." I , s The applicant must cal or 1 rec)yj red inspections. Complete drawing on reverse side. ' 9•� ' ' I - Signedix Title: `cs y�if��,,.. frDate: /7! �- 1 DEPART USE ONLY Application Accepted by W Area ❑ Stk 465-6781 ; Additional Comments: ( [] Lodi 369-3621 s i IF Pit or Gout Inspection by ' Date Manteca 8823-7104 § Final Inspection by Date ri /" - 1 � Tracy 835=5385 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:",*•CA, 95ZOI 3 # FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO- ` 1 ' `A S _- - � , .. �f� , "��.';,, "� rte,: ,.�� •S 6�r .��i��o�_.r_�„�.ie:..