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-• APPLiCATION FOR PERMiIT SAN JOAQU'iN LOCAL HEALTi DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (205) 466-5781 DATE ISSUED PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (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. 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San.Joaquin Local Health District. Job Address �a&Z - 77WRA.7 R,5' Ayd Subdivision.Name Owner's Name n, 41 CA jR .1Q.. Addressd. �, , s'� Phone S276 contractor's Name Cj ' T�.,. �$meq License No. Z Phone .T,YPE OF WELL/PUMP WORK., NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ` SYSTEM REPAIR -OTHER U DISTANCE TO NEAREST: SEPTIC_:TANK /'0 SEWER EINES 4f s' DISPOSAL FLD,- r PROP. LINE , FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom EJ Manteca Dia. of Well Excavation Domestic/Private 'Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Del to Irrigation Type of Casing V g anon �,SIC Approx. ❑ Eastern — Depth Specifications Cathodic Protection p Depth of Grout Seal ❑Geophysical ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Z State Work Dane Well Destruction Well Diameter Sealing Material {top 50') Depth Fi11er Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j� (No septic tank or seepage pit permitted if public sewer is 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 Capacitt No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity+ Method of Disposal 1� SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ C LEACHING LINE ❑ No. & Length of lines Total length/size1, FILTER BED Distance to nearest: Well Foundation. Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �� r s - • 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 workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 mous+t call fore 11 required inspections. Complete drawing or reverse side. �! Signed X f1, Title: Date: RD- RT UE Application Accepted "by Area / / Stk 456-6781 Additional Comments: CJL/J - //C di. 369-3621 Pit or Grout Inspection by Date r -�, ' U Manteca 823-7104 Final Inspection by '! Date ''l u L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO —� EH 13-24 REV. 10/82 10/82 500 ' 14-26 � ' i