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A t, ' ,.. ? ?PLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. :� 7 1 Telephone (209) 466-6781 1 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED J��,jy (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. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1,962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address--4y ISI, .r f' —."j.v PD Lc�j)*' Subdivision Name Owner's NameAddress ,�js Phone C � Contractor's flame _ 7 �, 6Le License No. Phone oU TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rQ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v v Industrial ❑ Open BottomManteca ❑ Dia. of Well Excavation Domestic/Private ❑Gravel PackTrac 13 Public ❑ y Dia, of Well Casing CjOther ❑ Delta Irrigation Approx. ❑ Eastern Type of Casing ❑ Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal Ll Other 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 501) _ Depth Filler Material (Below 50') L TYPE OF SEPTIC WORK: NEW INSTALLATION —I REPAIR/ADDITION r L.. (No septic tank or seepage pit permitted if public sewer is � Installation will serve: Residence _ Commercial ' Other available within 200 feet.) Number of living units: bedrooms �' U•��e S.!? 71-J17 9 '�� Number of Lot size S'�G,(�s Character of soil to a depth of 3 feet: s� Water table depth A 9 f SEPTIC TANK Type/Mfg �j��e�-t— ��l Capacity � P yam_ No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well -,t, Foundation 2;f3 ' Property Line L!l f LEACHING LINE ❑ No. & Length of lines Total length/size 2 e FILTER BED Distance to nearest: Well e4 0- Foundation _ ?f Property Line /e SEEPAGE PITS Ej Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 workman's 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 applicant must call f r all required i pec tions. Complete drawing on reverse side. Signed X Title. � �' Date: _/,Z l-,;,pI� Application Accepted by DEPARTMENT USE ONLY Area Stk 466-6781 Additional Comments: Lod i 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Q 1 Date /'�r- Z Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEED BASE AMOUNT DUE AMOUNT REMITTED INF ,�ECEIVEO 8Y DATE PERMIT N0. _ EH 13-24 REV. 10/82 -+^ 14-26 10/$2 500.