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I h APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 147 Telephone (209) 466-6781 f DATE ISSUED 4(J r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 ��ly 7-2 A G V tgly_P Subdivision Name Owner's Name Address / G4 " a-44-1 Phone Contractor's Name A License No. Phone TYPE OF WELL/PUMP WORK: ! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Iti f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ "V DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A -FOUND TA ION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE �1, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial i. ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private 0 Gravel, Pack ❑ Tracy Dia. of Well,Casing L] Public ❑ Others [] Delta,,: �'�� >1`;"s Type of Casing ;fit Irrigation Approx. [] Eastern Specifications"3 ❑Cathodic Protection Depth s Depth ofbGraut Seal ❑Geophysical Type o _-. ----,- ---•N.- --�---- f',Grout. t LJ Other —Surface Seal;Installed by Repair Work Done-❑. Tgpe`of PumpH.PP. d NNS -State Work Done Well Destructio i.0 �-_Wel1�D.iameter _ Sealing Material (top 501.) r r Depth Filler Material (Below 50') Ir _ p TYPE OF SEPTIC WORK: NEWiINSTALLATION T' REPAIR/ADDITION U (No septic tan k or seepage pit permitted if public sewer is available within 200 feet.) 3) Installation will serve: Residence _ Commercial _ Other 41A- ry �Rr-"At PX.4•✓� � Number of living units:?".___ . Number of bedrooms Lot size � Character of soil to a depth of 13 feet: Water table depth SEPTIC TANK ( i�Type/Mfg _ ?•��, Capacity No, Compartments PKG. TREATMENT PLT. ❑ ;'Type/Mfg_, Capacity Method of Disposal " Septic Tank ;Distance to nearest: Well rrpFoundation Property Line _f. Destriu t' LEACHING LINE ii No. & Length of+line s Total length/size 7' FILTER BED i1i'Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ a Depth Size Number . SUMPS 11,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, I shall employ persons subject to workman's compensation laws of California." The applicant must call for required inspections. Complete drawingonreverse side. Signed X Title: Date: F,9R DEPARTMENT USE ONLY '� + " Application Accepted by ��• � `•" Area e7 ❑ 5tk 466-6781 r Additional Comments: ❑ Lodi 369-362.1 Pit or Grout Inspection by r-Date Cl Manteca 823-7104 3 Final inspection by _ Date ice _ ❑ Tracy 835-6385 f Applicant - Return all copies to: Environme Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201t FEE BASE 'AMOUNT DUE ( AMOUNT REMITTED RECEIVED BY DATE PERMIT+ NO. INFO IM 13 EH 13-24 REV. 10/82 10/82 500 14-26 r