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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT yy?? 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. c /7 L 10 Telephone (209) 466-6781 DATE ISSUED :j o2q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) L 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. 1862 for well/pump and the Rules and J R/e�gulati ns of fttt��iQSSaan Joaqui Loca Health i ct. Job Address V,�p.y6� / � O IT I� i am �s�e Owner's Name /-s-��T- e�yy_dD ,. Add ass Phone �Contractor's Name s1ti� •r4r -),�., '/Cense No. 7i , Phone o4) L TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE LFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOPS Fl Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation L ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. FIEastern Specifications ❑Cathodic Protection Depth_. Depth of Grout Seal L ❑Geophysical Type of Grout ❑Other Surface Seal Installed by L Repair Work Done ❑ Type of Pump, N.P. State Work Done — Well Destruction ❑ Well,-0iameter Sealing Material (top 501) Depth Filler Material (Below 50') L TYPE OF SEPTIC WORK: NEW INSTALLATION _'�IE_I 'REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is C available within 200 feet.) ' Installation will serve: Residence -/,, Commercial Other Number of living units: _L Number of bedrooms _Lot size ` 6 I Character of soil to a depth of 3 feet: Water table depth h. SEPTIC TANK J- Type/Mfg �//t�/ Capacit No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method oY-Disposal L SEWAGE SYSTEM ON ❑ Distance to nearest: Well a< 1 Foundation 0 Property Line ES LEACHING LINE ❑ No. & Length of linesTotal length/si i 2{ L FILTER BED E] 'Distance to nearest: Well � Foundation Prop ' ine SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 6' 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 fob 1 required spections. gm to drawing on reverse side. Signed X le: Date: ` FO A T E USE ONLY / 7/ ❑ Stk 466-6781 Application Accepted by ^. 11/� Area Additional Comments: E] Lodi 369-3621 L Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie to: Environmerital Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO '93- 171 93— / / .I3'� �3�a4��3 J 7,z L EH 13-24 REV. 10/82 10/82 500 14-26