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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I Telephone (209) 466-6781 DATE i55UE0 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L � (Complete in Triplicate) h y4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein described. This application is made in compliance with San Jo&quin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations f the San Joaquin Local Health District. Fl. Job Address 1 C Subdivision Name Owner's Name Address _Sl.�i.,,c�� Phone Contractor's Name- ` License No. _3 2—Z 7-Z Phone 0. G TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION SYSTEM REPAIR OTHER E] I 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 U Open Bottom F'j Manteca Dia, of Well Excavation 1 Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing Public [—I Other Delta Type of Casing U Irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal U Other Type of Grout � 1 t Surface Seal Installed by i Repair Work Done FJ_ Type of Pump H.P. State Work Done Cr Well Destruction LJ Well Diameter Sealing Material (top 501) ( Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION u, PAT ADDITION U (No septic tank or seepage pit permitted if public sewer As available within 200 feet.) Installation will serve; Residence Commercial _ Other ri Number of living units: _L_ Number of be rooms Lot size (1.�� s Character of soil to a depth of 3 &f : 1Water table depth fJSEPTIC TANKType/Mfg Kch_ C 1izc _ Capacity .- OCA No. Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal -+ Distance to nearest: Well 4�e Foundation —--� Property Line -` LEACHING LINE Fd—�.No. & Length of lines ; L-�-4 L,,r Total length/size J9-0 --?- y C ' FILTER SED ❑ Distance to nearest: Well Foundation __Lro Property Line W� SEEPAGE PITS Depth Size LL Number SUMPS IJ Distance to nearest: Well t,$-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 ,I permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 applica must c�IZor11 required inspections. Complete drawing n verse side. -- Signed X / Title-, Date FOR DEPARTMENT USE ONLY l Appl ation Accepted by Area Stk 466-6781 { Additional Comments: ; �'?�� .{ r-(JIALtv Lodi 369-3621 Pit or Grout Inspection b Date �---I Manteca 823-7104 Final Inspection by / Date Tracy 835-6385 6 Applicant - Return all copies of E ironmental Health Permit/Services i1�rE,_ea/eNd Ave., P.O. Box 2009, Stk,, CA 95201 I - FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO F � 3 _�3 -� w EH 13-24 REV. 10/82 10/82 500 ,A 9C