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APPLICATION FO PERMIT SAN JCAQUIN LOCA! HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. a 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 I 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. k Job Address �`/S`S �1' Subdivision Name Owner's Name .. i/�J17 O Spy Address �B"/vr'✓` �2�,�' /C.1, w Phone r Contractor's Name License No. Phone S-,7,7— TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ Industrial ❑ Open Bottom ❑Manteca Dia, of Well Excavation ❑ Domestic/Private .,^-0 Gravel Pack [ Tracy .Dia. of Well Casing _ ❑ Public ❑ Other _. ❑ Delta Type of Casing " Irrigation Approx. ❑ Eastern Specifications 1 Cathodic Protection" Depth ElhPtti � Depth of Grout Seal � ❑Geophysical Type of Grout U1 1 ❑Other y _ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work'Done —C Well Destruction ❑ Well' Diameter Sealing Material (top 50') L '� Depth ` Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑I REPAIR%,ADDITION {No septic tank or seepage pit permitted if public sewer is f available within 200 feet.)�_ s tb Installation will serve: Residence /'7,Commercial _,..-Other ,' ___ --• - Number of living units:; _ Numtier of bedrooms -Lot size Gyt2 Character of soil to a depth-of-3 feet: 'r ,hFiffy CdA Water table depth SEPTIC TANK " Type/Mfg_,A_sp Cf)Sr Capacity /,Too No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well GQ Foundation A•p ' Property Line / DESTRUCTION ❑ 11111 LEACHING LINE U' No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ :Depth Size Number SUMPS 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 is 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 mu call for all required inspections. Complete drawing on reverse side. �Y Date: Signed X .._�� `� -�� Title: // � s FOR DEPARTMENT USE ONLY ❑ Application Accepted by Area Stk 466-6781 Additional Comments: �] Lodi 369-3fi21 Pit or Grout Inspection by Date Manteca 823-7104 n835-6385 Final—Inspection by Date �:`7 � ❑ Tracy Applicant - Return all copies to: vironmental Health Permit/Services 1601 E. Hazeltbr Ave., P.O. Box 2009, Stk., CA 95201 ------------------------------------------------- FINFD BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. Ll S., too Li— 7 C 10/82 500 EH 13-24 REV. 10/82 I 14-26