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APPLICATION FOR PERMIT SAN JOAQUIN LOCALHEALTH DISTRICT f �. li 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, �3 -` ,7U ,r Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) � �` Application is hereby made to the San Joaquin Local Health District for a permit �cinstI�p,�ruct 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 Regul,atia4��D� e San Joaquin Local Health District. Job Address_: VCS F/, 7 �C.4z& 0212 Subdivision Name Owner's Name.,.JE'r* je} F Address �ZS7l�'A( 7"tr '�U /�}C4A4 Phone Contractor's Name � �3� •-,�[S� �z/ASbN -VVJUJg&l License No. �p�z� Phone 7_42/-337 7 I !{ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONg SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK a-04:9.4 SEWER LINES DISPOSAL FLO. PROP. LINE �/Q FOUNDATION -- AGRICULTURE WELL - OTHER WELL PITS/SUMPS f r� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS :f I Industrial ham/ Open Bottom Manteca Dia. of Well Excavation ' --7 N 6omesti7Private Gravel Pack r]Tracy Dia.of"We 1 Casrng ❑ Public F-1 Other Delta Type of Casing Irrigation Approx. Eastern �] Depth Specifications l 1 cathodic Protection �.y Depth of Grout Seal 7 v 1 ❑Geophysical Type of Grout S PLS 1 ❑Other T9- � L41��7i1T ��Qti --�,� 'Surface Seal Installed by / Repair Work One [J Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') Z r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION U (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 sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal d SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line DESTRUCTION ❑ + LEACHING LINENo. & Length of lines Total length/size U FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [7j- Depth Size Number 4LSUMPS . _�_EJ,, ,9istance,_to nearest; ty .r-Well� Foundation Proper .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 , i 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 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 applican ust call or all r quir,d inspections. Complete�drawing on reverse side. Signed X_ -,_. � p Title: C Date: � FOR DEPARTMENT USE ONLY Application Accepted by �/ Area (1! E] Stk 466-6781 E Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date (1 u7 Manteca 823-7104 Final Inspection by Date r C�! L7 Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Avo, P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 = 10/82 500 14-26