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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.- HAZELTON AVE., STOCKTON, CA PERMIT NO. � Telephone (209) 466=6781 3 PERMIT EXPIRES k-YEAR FROM DATE ISSUED 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 7Vfi ,V Subdivision Name gle Owner's Name Address SW&Adle Phone Contractor's Name License No. �'ji��y]� Phone 3g�/ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT • 4 DESTRUCTION ! PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial U Open Bottom Manteca Dia. of Well Excavation L_IDomestic/Private ❑Gravel Pack Tracy Dia. of Well Casing I] Public CJ Other Delta Type of Casing Lj Irrigation Approx. Eastern LICathodic Protection Depth Specifications Depth of Grout Seal 1-1 Geophysical Type of Grout LJ Other1 Surface Seal Installed by -4� ' Repair Work Done LJ " Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is k available within 200 feet.) j Installation will serve: Residence Commercial _ Other Number of Ii-ving units: -,/— Number of bedrooms _ Lot size QG Character of'soil to a depth of 3 feet: �/�q� Water table depth SEPTIC TANK Type/Mfg ��- ` _e _ _ Capacity, f 7.BL7 No. Compartments Z! 61 PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of'Disposal" SEWAGE SYSTEM Distance to nearest: Well er Foundation jd'� Property.Line. ^7-04 �'f DESTRUCTION LEACHING LINE r �g/3ength of lines Total length/size-•---, r i FILTER BED G Distance to nearest: Well -Foundation- --i Property Line SEEPAGE PITS �J e �/�_ Size Number 4 SUMPS T1s 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 I permit is issued, I shall not employ any person in such manner as to become subject to workmank 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." i � I The applicant must call for all required ins tions. Complete drawing on reverse side. - Signed X Title: Date: 3-7-�. FOR QEP R7 ON Application Accepted by ea G� 3 Stk 0.66-6761 1 , Additional Commen . Lodi 369-3621 Pit or Grout Insp ion by ate �i Manteca 823-7104 Final Inspection by Date - a ❑ Tracy 835-6385 Applicant - Return all ie o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO � �`I S• o CbS f-7 -AL1 EH 13-24 REV. 10/82 10/82 500 14-26 {r