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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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 R g �ttioys f le .$yo_ oaq ocal ea th District. Job Address / Subdivision Name 4// Owner's Name +�1',,�5�1 �" Address A Phone Contractor's Name�y�L .c-� 1J License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PIMP INSTALLATION SYSTEM REPAIR OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /O 0 JO'` DISPOSAL FLO. PROP. LINE 7 FOUNDATION AGRICULTURE WELL OTHER WELL Q Q-�—PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom Manteca Dia, of Wel l Excavation , ,ZX flee 4 ❑ Domestic/Private �avel Pack Tracy Dia. of Well Casing .1e,�,-Ze/y gkfubl is EJ Other Delta Z.,O/y irrigation Type of Casing •� U 9 Approx. �Eastern Specifications n Cathodic Protection Depth Depth of G ❑Geophysical rout Seal `5 do _ `� �� Type of Grout /y L 1-1Other ! ((�� /Surface Seal Installed by � F3Z-74 Repair Work Done nType of Pump H.P....]O'y``1AAW4'5'4 Qte Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (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 soil 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 EWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE [f No. 8 Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line 5 tPAGE PITS Depth Size Number SUMPS L..1 Distance to nearest: Well Foundation Property Line dI�POSAL PONDS El 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. Rome 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 workmanK 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 or 11 required inspections. Complete drawing on reverse side 1571gned %�_ /�ri1v/ ��,.le: L�911..f1///'/l1lotDate: " S F R DEP RTMENT USE ONLY / Application Accep by — Area ❑ Stk 466-6781 Additio ents: / f 6 l f e >�Lodi 369-3521 Pit Grout I pection by Date ❑ Manteca 823-7104 Final 117spectlon by _ Tracy 835-6385 Applicant - Return all copies to: r mental 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 0 4 EH 13-24 REV. 10/82 c 10/82 500 14-26