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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED JJ-ZS 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 Joaquin Local Health District. Job Address Subdivision Name Owner's Name i A je geya y_ Address V 7,03 g«,l > Phone Contractor's Name - 041041f Uf� � License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DFSTRUCTION U PUMP INSTALLATION SYSTEM REPAIR U OTHER U 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 I J Industrial E' U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing �- Public `+ Other ❑ Delta Type of Casing Li Irrigation Approx. Eastern Depth � Specifications J Cathodic Protection p Depth of Grout Seat Geophysical Type of Grout r U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 6 w Well Destruction U Well Diameter Sealing Material (top 50'.) _ Depth ..Filler Maferial-(Below 50') TYPE OF SEPTIC WDRK: NEW INSTALLATION REPAIR/ADDITION '0 (No septic tank or seepage pit permitted if public sewer is r available within 200 feet.) Installation will serve: Residence _ Commercial _ Other �(!p Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK Type/Mfg Capacity No. Compartments ; PKG. TREATMENT PLT. Type/Mfg Capacity _ Method of-Risposa1 SEWAGE SYSTEM Distance to nearest: Well &S/ Foundation `f I PropErty Line j c _DESTRUCTION LEACHING LINE ICYNo. & Length of lines • fi 7 Total le6 th/s•ize. FILTER BED Distance to nearest: Well Foundation !�gO`F Property tine SEEPAGE PITS F-1 Depth Size Number SUMPS CI Distance to nearest: Well .FBundation Property'Line DISPOSAL PONDS ❑ - 'V I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordina'nces,.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 t 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 all equired inspections. Complete drawing•on reverse s-id"e. Signed X ,Ge�J Title: Date: /� ❑i Application Accepted by DEPARTME USE, LY Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date — n/ L7 Tracy 835-6385 6""'' Applicant - Return all copies to: Envir ental Health Permit/Services 1601 E. Hazelton A)gl P.O. Box 2009, Stk., CA 95201. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY- DATE �; PERMIT NO. INFO EH 13-24 RFV. 10/82 10/82 500 14-26