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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ttt�I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. -53 ( Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED C (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 San Joaquin Local Health District. Job Address Cggo bd Subdivision Name 4 Owner's Name 29 a ca Address . Contractor's Nam ` Phone �► License No. Z 2- Phone TYPE OFtWELL/PUMP WORK: NEW}WELLWELL REPLACEMENT, 1 ❑ ❑ DESTRUCTION PUMP INSTALLATION ❑ � -� C/O ' SYSTEM REPATR ❑l t�� `"OTHER � DISTANCE TO NEAREST: SEPTIC TANKU 4� SEWER LINES DISPOSAL FLD. PROP. LINE #1 + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � Industrial ❑ Open'BottomManteca t U Domestic/Private 1 Dia. of Well Excavation ` [�Gravel Pack ❑ Tracy Dia, of Well Casing r1,� Public ❑k Other Delta irrigation Type of Casing , Approx. � Eastern `F-1 Cathodic Protection Depth Specifications ❑ Depth of Grout Seal Geophysics] � P � LJ Other Type of Grout Surface Seal Installed by Repair Work-Done•-Q—Type-of"-Pump -ice--H.p----. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth e-Filler Material (Below 60') _ a TYPE OF SEPTIC WORK: NEW INSTALLATION .I RE�IR/ADDITION ' LJ (No septic tank or seepage pit permitted if public sewer is ]nstalTationwi'.1 available within 200 feet.) I-•serve: Resid'ence�� Commercial Other Number o1=v,ing units: �— Number of edrooms Lot size Ctlaracter of so.l to a,depthro-f 3tfeet: Water table depth [ SEPTIC TA K;,r i��/j Type/Mfg } 7 Water LJ�, , Y _fln�4 No. Compartments PKG. TREATMENT PLT. Type/Mfg a ; Capacit'y �" '°--"" ` " Mhod'o`f Disposal SEWAGE SYSTEM Distance tH a!nearest: Well Foundation DESTRUCTION ❑ Property Line LEACHING LINE L� No. & Length,of lines -- Q Total �ength/size .420 ' X Z FILTER BED ❑ Distancef`o neares_t:' Well WO�-a- Foundation /D Property Line 7f'4- SEEPAGE PITS ❑ Depth _ f,,? .„ Size Y 7 LAe) Number. �� i SUMPS �,� Distance to` earest: Well �(�� Foundation /0� -- Property Line DISPOSAL PONDS �r r I hereby certify that I have prepared thipplication 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. r 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 ca1J fo all required inspections. Complete drawi'n; or everse side. Signed X 1/ Title: Date: 1-_ -7 FOR D ARTMENT USE ONE Ap cation Accepted b Area _- ❑ Stk 466-6783 # Additional Comments: Lodi 369-3621 yy Pit or Grout Inspection by Date ❑ Manteca 823-7204 f Final Inspection by Date _1+f �3 ❑ Tracy 835-6385 Applicant - Return all copies to: . Enviro nmentelial Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUET AMOUNT REMITTED RECEIVED BY DATE, PERMIT NO. INFO �s } 1y 33 -33_�. { EH 13-24 REV. 10/82 # 14-26 20/82 500 5