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APPLICATION FOR PERMIT 4 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) ° 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 Sah-'Joaquin Local Health District. Job Addressi ) ��g � 7'�1��,��g•S Subdivision Name � Owner's Name Address Phone Contractor's Name LTj��L,L � "-- --- License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR OTHER F +J -DISTANCE"TO NEAREST:' EPTICTANK SEWER L�NE5 ��" �°DISPOSAL�FLD� � V PROP. LINE � "m FOUNDATION ^AGRICULTURE WELL OTHER WELL - PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 17 Industrial ❑ Open Bottom F� Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ED Tracy Dia. of Well Casing 0 Public Ej Other ❑ Del to -r irrigation I Type of Casing UApprox. Eastern Specifications N E)Cathodic Protection Depth tr _T� 9 Depth of Grout Seal ! Geophysical ''� '" �^. 9 Other Type of Grout Surface-Seal'Installed by Repair Work Done (] Type of Pump F1.P. State Work Done Well Destruction ❑ Well Diameter Sealing-Material ,(top-50'-)—.--- Depth Filler Material-Below 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank ora seepage pit permitted if public sewer is fb I available within 200 feet.) Installation will serve: Residence commercial Other 1 u �� i 4 Number ofNj+wing units: _J__units: of bedrooms - Lot size ? t Character of soil to a depth of 3 feet: i + . t Water table depth L �J SEPTIC TANK Type/Mfg Capacity aa No. Compartments PKG. TREATMENT PLT.- ] Type/Mfg Capacity f Method of Disposal SEWAGE SYSTEM: Distance to nearest: Well Foundation _/—!I P-'� Property Line ' DESTRUCTION Cl r LEACHING LINE No. & Length of lines,1QQ�_ T Total length/size § FILTER BED �r Distance to nearest: Well FoundationFTproperty Line i SEEPAGE PITS ] Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F 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 cal for 11 re uired inspections. Complete drawing on reverse,sjde. /J i Signed X_ Title: Date: 7�' �7_' � A ( FOR DEPARTMENT USE ONLY" Application Accepted by Area <' [f 5tk 466-6781 a F Additional Comments: ZWe Ap � ;61 E] Lodi 369-3621 i Pit or Grout Inspection by Date Manteca 823-7104 { Final Inspection by Date Tracy 835-6385 ; Applicant..- Return all copies to: Environ a tal 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 !EH 13-24 REV. 10/82 10/82•'500 14-26 _. . i