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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. V-303 V 3 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 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 /y 749 N 7, ' Tt7,i/ KDy L#D/Subdivision Name Owner's Name 3A,& zguc - e4L/7D_PJAZdAddress _SAm,5: Phone '?41-4 ee-ry Contractor's Name i;, &WA> License No. .rf;yj y74 Phone 6!j�S397% � TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r ^\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V" Industrial Open Bottom E]Manteca Dia. of Well Excavation 1-1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public E—i Other Delta Lj Irrigation Approx. [—] Eastern Type of Casing Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') -L J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial X available within 200 feet.)Other �`GV•b.ro S•R X1'317 Number of living units: �- Number of bedrooms Lot size SA t2E$ Character of soil to a depth of 3 feet: ZVA by K LA+4'm Water table depth d 9 7 SEPTIC TANK Type/Mfg &AM&_ Da41— Capacity 1 gOe, No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well 2. ¢ Foundation L 0 Property Line 2,& LEACHING LINE U No. 8 Length of lines ,yam Total length/size FILTER BED Distance to nearest: Well 2,00 4- Foundation' Property Line /p SEEPAGE PITS Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 workmanb 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 call f r all required 1 pections. Complete d�ra�win,g.�on reverse side. Signed X_�� Title: 6e�lA , Date: .,/,yF(J4y DEPARTMENT USE ONLY Application Accepted by [,¢/!A' Area /Z F1 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by � �� tZ.• Date Tracy 835-6385 Applicant - Return all copies to: Environ ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 14-26