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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -7y� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. .2-- • 0 3 Telephone (209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ,;L 3 �! (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_/ 7��_..lV: T/ 72kl VAl Rbc 4.d&/Subdivision Name Owner's Name C Z,, Address Phone �G S Contractor's Name E 1,V,0 License No. ,�- Phone / TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F.LD. PROP. LINE FOUNDATION { AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS VV Industrial Open Bottom ❑ Manteca Dia, of Well Excavation 17 Domestic/Private (�Gravel Pack Tracy Dia. of Well Casing 17 Publics �jOther Delta Type of Casing V Irrigation Approx. F-1Eastern Cathodic Protection Depth Specifications Q Geophysical Depth of Grout Seal LJ Other Type of Grout Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) 1 F Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U or see REPAIR/ADDITION — (No septic tank i P page pit permitted if public sewer is Installation will serve: Residence _ ComX Other _-S)mercial available within 200 feet.) of Number of living units: A— lNumber bedroomsg�-1 f7 Lot size Character of soil to a depth of 3 feet: s Water table depth / . r SEPTIC TANK [ Type/Mfg} Capacity J qp d No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: ' Well Zn6g.,1= Foundation Z O` Property Line 2Z7,' r LEACHING LINE U No: & Length of lines Total length/size 0 FILTER BED Distance to nearest: Well Foundation's Property Line SEEPAGE PITS Cj Depth ) Size1 Plumber SUMPS — Distance to nearest. Well Foundation Property Line DISPOSAL PONDS t� t 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 t permit is issued, I shall not employ any person.in such manner as to become subject to workman b 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 fQr all required i Cy% q pections. Complete drawing on reverse side. Signed X i Title: 4 Date:1. DEPARTMENT USE ONLY Application Accepted by Area /� El Stk 466-6781 Additional Comments: Lodi 369-362.1 Pit or Grout Inspection by L Date Manteca 823-7104. Final Inspection by J Date / .- a 0 Tracy 835-6385 Applicant - Return all copies to: Environm ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE BASE AMMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT NO. EH 13-24 REV. 10/62 14-26 10/82 500