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APPLICATION FOR PERMIT *ftw SAN JOAQUIN LOCAL HEALTH DISTRICT {� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED Je2 � PERMIT EXPIRES 1 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 workherein 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 d ulationssoff"the San Joaquin Local Health District. Job Address 4?11 j /V.�elg/•-ZC Ae Subdivision Name Owner's Name L4W923 Wo! J�Yy),/ &!J AddressC�'9 Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL 0 WELL REPLACEMENT DESTRUCTION❑ _J PUMP INSTALLATION 0 SYSTEM REPAIR OTHER 0 UJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom []Manteca Dia, of Well Excavation 17 Domestic/Private El Gravel Pack E]Tracy Dia, of Well Casing ❑ Public E]Other O Delta Irrigation Type of Casing De (--) 9 Depth Eastern Cathodic Protection Dptthh Specifications �]Geophysical Depth of Grout Seal 17 Other Type of Grout Surface Seal Installed by Repair Work Done C7 - Type of Pump H.P. State Work Done Well Destruction (D Well Diameter Sealing Material (top 50') Depth Filler Material- (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: ResidenceCavailable within 200 feet.) S _ bedrooms _ Other Number of living units: Number of bedrooms Lot size ` .y` Character of soil to a depth of 3 feet: jg;� Water table depth rj 0 SEPTIC TANK Ej Type/Mfg Capacity J�.U� No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. 8 Length of lines Total length/size FILTER BED ED Distance to nearest: Well ay Foundation Property Line SEEPAGE PITS (] Depth Size Number SUMPS [J_ Distance to nearest: WellFoundation Property Line 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 workman4 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 applican m s call r it required inspections. Complete drawing on reverse side. Signed X d ./✓Y)� . O . Title: (/'k.+yl, Date: I6 fl:i� F DE RTMENT USE ONLY Application Accepted by I y Area e9 C] Stk 466-6781 Additional Comments: �— 0 Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Dater Tracy 835-6385 Applicant - Return all copies to: Environmen�ealthices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �y FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. L, INFO - EH 113-24 4-26 REV. 10/82 �°`�� ' �/L('C-� f 10/82 500