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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 54 for sewage or No. 1862 for well/pump and the Rules and Regulations of 1th'e San Joaquin Local Health Dis D d Job Address fz 3� a'YI W �oZ7�L. S�ubdi ion e _ Q. Owner's Name .S 7L Address /' ��. J22, S 3 Phone ;-'V 5 g 3 1 Contractor's Name p n, co- License No. � '!t!22 PhonedQL22_1 -S-Gi3 I �& TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ // C DISTANCE TO NEAREST: SEPTIC TANK /�.S SEWER LINES r y1b-4� DISPOSAL FLO. O . PROP. LINE O 4 - kz, FOUNDATION *Q AGRICULTURE WELL fa ee r . OTHER WELL PITS/SUMPS b }c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �c l� Industrial (J Open Bottom ®Manteca11 Dia. of Well Excavation / }�Domestic/Private Gravel Pack Tracy Dia. of Well Casing 6 t Public I Other Delta Type of Casing PVC e—lasc 140 Lj Irrigation 126Approx. Eastern De th Specifications '�cZS, [�Cathodic Protection p Depth of Grout Seal. _Cy jt4 Geophysical Type of Grout YP 'l1 LJ Other 2.1 CSC'►'+'►�"�+ Surface Seal Installed by Repair Work Done ❑ Type of Pump S u e H.P. State Work Done Well Destruction F� Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LJ (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: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION Q LEACHING LINE Lj No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [_j Depth Size Number SUMPS U 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, 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 �st c 11 fora 1 required inspections. Complete drawing on reverse side. Signed X Title: �� /-- Date: 02 f3'—g3 �.1IRTM11T3JULYApplication Accepted byArea CD Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by O1 Date Manteca 823-7104 Final Inspection by Date �' �{ Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/ ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO FS3--7 o - y EH 13-24 REV. 10/82 10/82 500 14-26 +owX-t- CL