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i APPLICATION FOR PERMIT. " SAN JOAQL'k".,LOCAL HEALTH DISTRICT Q n�J 1601 E. HAZELTON AVE_ STOCKTON, CA, PERMIT NO.U q " 1 Telephone (209) 466-6781 DATE ISSUED "_da PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is,hereby made to the San Joa�uin.Local Health Dj'strict 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 oaOuin Local Health District, Job Address �' gVy 4W_ Subdivision Name Owner's Name t' t ddress Contractor's Name ?l2Y„may `,icense No, i.� t'%. Phone, TYPE OF WELL/PUMP WORK: NEW WELL I [] WELL REPLACEMENT ❑ DESTRUCtION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑• OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J� FOUNDATION AGRICI]LTURE WELD 'OTHER WELL PITS/SUMPS, 1 INTENDED USE TYPE Or WELL' PROBLEM AREA CONSTRUCTION SPECIFLCATIONS Industrial U Open Bottom' 0 Manteca Dia. 'of Well' Excavaton ❑ Domestic/Private ❑,Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public Other ❑ Delta T ype of Casing F, irrigation Approx. ❑Eastern SpeCificatio,n4 F-1CathodicProtection Depth --- ` Depth of Grout Seal ❑Geophysical ! Type of• Grout ' U Other ! Surface Seal Installed by Repair Work Done [) Type of Pump I H.P. State Work Done Well,Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: . NEW INSTALLATION ❑ 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; / Numberiof bedrooms _j___ Lot size `�<< / Y Character of soil to a'depth of 3.feet;I,.'- >tf-,.�Cr --�-rs �__ Water table depth 4J + SEPTIC TANK Cj Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM !,� Distance to nearest: ,Weil Fau'ndation Property Lirle DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size I FILTER 'BED ❑ Distance to nearest: ,Well Foundation ,Property Line SEEPAGE PITS '❑ Depth •• r Size . .-T1- /•:v- Number y SUMPS Distance to nearest: .Well, I&/ f Foundation ! y��#`_ Property ,Line r 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 subjegt 'to workmans compensation laws of California.” ContraFtor'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 pelsons'subject to workman's compensation laws of California." The applicant pst call for frall iredinspections. Complete draw'np on re"rse'side,' .1 Signed X — �7�C? Cy. ' rcYE ,_G:� Title,: -� . Date: IF R DEPARTMENT USVPNLY Application Accepted by Area ❑ Stk 465=6781 Additional Comments: Lodi 369-3621 Pit or Grout' Inspection by Date ❑.Manteca 823-7104 Final Inspection by Date, 3—�/— D ❑ Tracy - 835-6385 Applicant - Return all copies to: Envirpnment Healttj rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 'BASE AMOUNT DUE I; AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. [NFO ' 14 EH 13-24 REV. 10/82 ! 10/82 500 14-26 s 1