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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) it 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 o�f/�he'San Joa it Local Health District. Job Address / /v O �W 10 . Subdivisi,on� //�ane Owner's Name�L $ fi•O�b6,<, ply.?/ Address W1liCOx GAb Phone Contractor's Namel` pa;l�nl '� S _ License No. �, b 9 _ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALL ION SSYYS{T�MjREPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK �pl� CSE�JE[; RS DISPOSAL DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 1d ELL PITS/SUMPS �+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom 71 Manteca Dia. of Well Excavation I Domestic/Private F-1 Gravel, Pack U Tracy Dia. of Well Casing Public Other ', Delta Type of Casing V Irrigation -Approx. [] Eastern ' ' "' Specifications �] Cathodic Protection Depth Depth of Grout-Seal Geophysical Type of Grout U Other it Surface Seal Installed by Repair Work Done [D Type of Pump \]Z)6 H.P. Jr State Work Done '?Vk ivb 9? 7-iW.6 vAye Well Destruction U Well Diameter :. Sealing Material (top 50' !: q C />r1� ..?�J'p :�u e Depth • I f Filler Material (Below 50') . TYPE OF SEPTIC WORK: NEW}INSTALLATION F-1 REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is ^q available within 200 feet.) a Installation will serve:� Residence — Commercial _ Other O Number of living units:,. Number of bedrooms Lot size Character of soil to a depth of 3 feet; Water table depth `[ SEPTIC TANK EI ,Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS D Depth Size Number SUMPS Ci Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1 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: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman, compensation laws of California." Contractor's hiring or sub-contr cting signature certifies the following: "I certify that in the performance of the work for which this permit issued shall ploy persons subject to workman's compensation laws of California." The applica u t 11 f r a required i spections. Complet�r ��tting reverse side, Sign X Title: J CTEjAl'T/Q J9 Date: R DEPARTMEN SE QN�� ❑ Application Accept) by ea Stk 466-6781 Additional Comments: - Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date �- — ❑ Tracy 835-6385 Applicant - Return all copie :Environmental 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� FSk cog 10/82 500 EH 13-24 REV. 10/82 14-26