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y APPLICATION FOR PERM.I 2 � It R7 SAN JOAQLi,; LOCAL HEALTH 'DISTRICT ��"� � � I�O� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J^/�67 Telephone (209) 466-6781 112 7 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LQ[;HLTE ISSUED (Complete in Triplicate) HLALIH DISTRICT 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 Joaqu. Local Health District, Job Address Subdivision Name _ Owner's Name Address 14141 p G � aU doe o tfhone Contractor's Name License No. `_;%66 j.y �/1 Phone �f/_/�_ Ia„� 'SES`— ��l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT ON F7SYSTEM REPAIR ❑� - OTHER F-1 - C%3 DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES DISPOSAL FED, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation mestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical ❑Other � Type of Grout (� Surface Seal Installed by Repair Work Done Type of Pum P'� v14195tdte Work Done z` Well Destruction ❑ Well Diameter Sealing Material (top 50') _ �J Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is r available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 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 �--t PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Ei 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 SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 this permit is issued, shall employ persons subject to workman's compensation laws of California." The applicant most c r all req inspecti s. Co drawing o verse side. Signed X e: Date: FOR DEPA TMENT USE 0 Application Accepted by ( /p►,Yy Area ^'f l0 ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by W h Date U Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies t nvirpnment ealth Permit/Services 1601 E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO X15 q a-7L�3 1 B3- ro(o7, EH 13-24 REV. 10/82 10/82 500 14-26