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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 7rr P 1601 E, HAZELTON AVE,, STOCKTON, CA PERMIT NO. �5��/� 7 f 4) Telephone (209) 466-6781 GATE ISSUED//-Orr- PERMIT /-6 -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 S>w and the Rules and Regulations of the San Joaquin Local Health District. Job Address ��S7z S, y 6f` ` o�9 4t,4 k A9, Subdivision Name , Owner's-Name /Qhh rrr �Q,�4�P o Address Phone Contractor's Name r ¢fp�,oPj"�*icense No. �!!/ G 70 _ Phone 107- S719 7 �1 TYPE OF WELL/PUMP WORK: rNEW WELL Q WELL REPLACEMENT DESTRUCTION I PUMP INSTALLATION SYSTEM REPAIR OTHER [] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS s Y } Fl Industrial Open Bottom Manteca Dia. of Well Excavation )Domestic/Private Gravel Pack Tracy Dia. of Well Casing C� � LJ Public Other [� Delta Type of Casing ,i"�e 1 I 1 F, Irrigation Approx. E] Eastern Cathodic Protection Depth Specifications � Depth of Grout Seal [ve/-th'i� ci r 6.e Geophysical Type of Grout (ris..sA_ 4= Other, Surface Seal Installed by rjwy,.B J! s Repair Work Done ❑ Type of Pump li la 1/y, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') y 3 TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (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 s Character of soil to a depth of 3 feet: `Watdr table depth SEPTIC TANK Type/Mfg x d ` Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation a Property Line DESTRUCTION LEACHING LINE `L) No. & Length of lines Total length/size FILTER BEDDistance to nearest: Well Foundation Property Line 1 SEEPAGE.PITS Cj Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS i I hereby certify that I have prepared this application and that thework 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 workman§ 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 must call f all required inspections. Complete drawing on reverse side. Signed X _ _�� „ '__ Title: 41.E A Date: �� *EPR DEPARTMENT USE ONLY Application Accepted by Area �^� Stk 466-6781 = Additional Comments: E] Lodi 369-3621 i ( 3 Pit or Grout Inspection by Date - Manteca 823-7104 [d A, Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: vironmental Health 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 p vU o� X7 /�d g�S / 8 -77f W EH 13-24 REV. 10/82 k-;,` 7�� 10/82 500 14-26