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APPLICATION FOR PERMIT r SAN JDAQUIN LOCAL HEALTH DISTRICT �/ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 8 z Telephone (209) 466-6781 r 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. Thjs application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or RD. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2.3 9'2<2 S 174ei5'o,41 Subdivision Name Owner's Name Og o d Address Phone Contractor's Name License No. T� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ °f1'`f'�"5 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q<<��'/ r� J •J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing r ❑Public �j Other ❑Delta Type of Casing ❑ Irrigation Approx. ❑Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical r E]Other Type of Grout Surface Seal.Installed by p Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I, REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is r - available within 200 feet.) Installation will serve: Residence _' Commercial _ Other Number of living units: Number of bedrooms _L Lot s�ii Character of soil to a depth of 3 feet: 15w �..1 COAL r! Water table depth �a t/7 SEPTIC TANK ❑ 1 Type/Mfg r�rN Capacity Goo No. Compartments 2 �`� , PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method. of Disposal Distance to nearest: Well /� Foundation Property Line r LEACHING LINE ,[Y] No. & Length of lines _. 19 Total length/size G FILTER BED ❑ Distance to nearest: Well Foundation Property Line - r SEEPAGE PITS ❑ Depth Size 'Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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% compensation laws of California." r, 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 pust call r all re fired inspect ns Co ete dra n on reverse side. Signed X � Tji Date:�d—O ' 6-2-- ONLY Application Accepted by /Jif' i/ Area to ❑ Stk 466-6781 Additional Comments: T ❑ Lodi 369-3621 ` Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by �,GfLd�. Date Tracy 835-6385 Applicant - Return all copies to: Environ tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 W.. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 # �J ( 10/82 500 14-26 �O