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APPLICATION FOR PERMIT 7 SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6731 _ DATE ISSUED 'J� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sar. 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 JoaquinLoc 1 H231th District. Job .address 77 _ o3F.2TS -"subdivision Name Owner's Name I�J ��_ Q�Q�} Addresses- Phonei�� Contractor's Name License No. _�,�1 � _ Phone TYPE OF WELL/PUMP 'AORK: NEW WELL Lf WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIRj lI OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIGN AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 10pen Bottom 17 Manteca Dia. of Well Excavation ( I Domestic/Private 17 Gravel Pack L; Tracy Dia. of Well Casing L7 Public C Other F- j Delta irrigation Type of Casing LV 9 Approx. ❑' Eastern Depth Specifications C Cathodic Protection Depth of Grout Seal L; Geophysi ca 1 L,IOther 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') f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _L Commercial _ Other Number of living units: �_ Number of bedrooms Lot size //�� 5 J- Character of soil to a depth of 3 feet: eggg„$t% Water table depth /d T SEPTIC TANK (_j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE No. & Length of lines / — r Total length/size FILTER BED Distance to nearest: Well Foundation - Property Line S� SEEPAGE PITS Depths Size Number i SUMPS Distance to nearest: Well /77 Foundation Property Line _]mob 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 workman� compensation laws of California.” Contractor's hiring or sub-contracting sig -re certifies the following: "I certify that in the performance of the work for which this permit i sued, I shall employ per sw subject to workman's compensation laws of California." The applic t call for 1 reqdidy4Actions. Compl * &,ingon reverse side. .— Signed Title: Dater L_ DEPARTMENT USE ONLY Q Application Accepted by Area ©8l S t k 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L] Manteca 823-7104 Final Inspection by _�/✓ y Date / ;-2 ❑ Tracy 835-6385 Applicant - Return all copies to: environmental Health :ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26