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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. c3 Y Telephone (209) 466-6781 DATE ISSUED ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z (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 Couhty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local„Health District. i Job Address - 7R-Ac-y BK. Subdivision Name Owner's Name Address ;177e_ Phone Contractor's NameJ� �j! -��f Phone �+y12��S � f++ .iru License No. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F_� DESTRUCTION ❑ (l`) PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ f 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 1-1 Industrial Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public CJ Other ❑ Delta Irrigation Type of Casing LJ Approx. ] Eastern Specifications F-] CathodicProtection Depth p 0 Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by w Repair Work Done FJ Type of Pump H.P. State Work Done M Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ] REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve.. Residence 5 Commercial Other Number of living units: f Number of bedrooms T Lot size Ac C>b' Character of soil to a depth of 3 feet: ZegZWater table depth SEPTIC TANK }�j( Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well /S-0` Foundation J,-L1 Property Line �� t LEACHING LINE No. & Length of lines Tot 1 length/size FILTER BED Distance to nearest: Well SOV Foundation Property Line J '2V SEEPAGE PITS ] Depth Size Number w SUMPS ] 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 permit is issued, I shall not employ any person in such manner as to become subject to workman�compensation laws of California.” j Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which II this permit is issued, I shall employ persons subject to workman's compensation laws of California." s The applicant must r.0 for ai quir"s)yitions. Complete drawl op reverse de. Signed Title: 7c.rydq :�__., Date: 1,*,_ 2`/J�2 _ Ik Application Accepted by MEN USE ONLYArea 47 [] Stk 466-6781 Additional Comments: !e ] Lodi 369-3621 3 S Pit or Grout Inspection by Date -7104 823-7104 _S4 Final Inspection b //��11 p Y' / Date �- � �- � Tracy 835-6385 (Tppiicant - Return all copies to:�Envi mental Heavices aielt e., P.O. Box 2009, Stk., CA 95201 ' FEE BASE UNT DUE AMOUNT .REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 14-26 IO/82 500 �t