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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. t Telephone (209) 466-6781 PERMIT EXPIRES ! YEAR FROM DATE ISSUED DATE ISSUED. ?f (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 23ITZ STON67 PA. 615. L.8k Subdivision Name Owner's Name 1. M C a_AXK Address ftRQX ZD2� oC! W Phone Wf2— 47„ # Contractor's Name License No. Phonewnn7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES : DISPOSAL FLO% . PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v 1 INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca - _ Dia. of Well Excavation ❑ Domestic/Private Gravel Pack-•* -❑ Tracy • Dia. of Well Casing s ❑ Public ❑ Other '❑ Delta Type of Casing I! V Irrigation A. Approx. ❑ Eastern Specifications S E)Cathodic Protection Depth : p f ❑ Geophysical Depth of Grout Seal- � 1 ❑Other, s r .� F Type of Grout I Surface Seal Installed by Repair Work Done.❑ Type of Pump , H.P. State Work Done sWell Destruction,U Well Diameter. Seal iFg.Material.(top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U` REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is G Installation will serve: Residence '�f Commercial ,» Other available within 200feet.) v`�) Number of living units: �_ Number of bedrooms _ Lot size /Z40- ' i Character of soil'to a depth of 3 feet• N Water table depth SEPTIC TANK Type/Mfg 5Capacity «dgZ! _ No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal W Distance to nearest: Well Foundation J Property Line SID5 p LEACHING LINE No. & Length of lines _.�_ — -70♦ Total length/size �I U FILTER BED ❑ Distance to nearest: Well Foundation /� Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 k this peAilssued, I shall employ persons subject to workman's compensation laws of California." The app] _call fo all requ' dins ctions.-..Camplet drawing on reverse side. ^ Signed X Title: ..[.L� Date: � Application Accepted by FOR DEPARTMENT USE ONLYArea ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection.by '�_ _.i x Date ❑ Manteca 823-7104 } Final Inspection by Date ❑ Tracy 835-6385 fr Applicant - Return all copies to: Environmen Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO q EH 13-24 REV. 10/82 10/82 500 14-26