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APPLICATION FOR PERM:i SAN JOAQUiN LOCAL HEALTH D STRiCT I501 E. HAZELTON AVE., STOCKTON, CA,, PERMIT N0. _ Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE=ISSUED DATE ISSUED (Complete in Triplicate) 4 Application is hereby made to the an Joaquin Local Health D' q istrict'fora 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 Joaquin Local Health District. V Job Address c S .Subdivision Name /' IQSS 0.►BO ;=. �� Owner's Name _ i8 ' �a�� Address W , V Phone <57'ZZ Contractor's Name LJ i License.No. Phone TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ .�.�,�--f6 .� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial L�pen Bottom ❑ Manteca Dia. of Well Excavation r - ==;tp;:vrire Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public Ej Other ❑ Delta OF Type of Casing Lj Irrigation Approx. ❑ Eastern ❑ Cathodic Protection � k Depth Specifications * Depth of Grout Seal 17 Geophysical � �� _ -•, Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well. Destruction F-1'4 Well Diameter Sealing Material (top 501) � Depth Filler Material (Below 501) ~ TYPE-OF SEPTIC WORK: NEW INSTALLATION L+� REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public'sewer is.. -- Installation will serve: Residence X,-- available within 200 feet7)--' Commercial -_,. Other � Number of living units: Number of bedrooms Lot size7j., Character of soil to a depth of 3 feet: �4 Water_table depth i SEPTIC TANK �' Type/MfgCa acit ,.ZO P y No. Compartments .2- PKG. TREATMENT PLT. ❑ Type/Mfg p Capacity Method of Disposal T � SEWAGE SYSTEM Distance to nearest; Well PropertyFoundation Line DESTRUCTION ❑ —� LEACHING LINE No. 8 Lenigth of lines QAte - khp.w Total length/size. FILTER BED ❑ Distance,1to nearest: Well Foundation Property Line 4 Size Number SEEPAGE PITS ( " Depth _ � ! G ©�! SUMPS Distance to nearest: Well /✓Q Foundation 3G? Property Line r + DISPOSAL PONDS ❑ i 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 Sari 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 became 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 must call for all required ins ections Complete drawing on reverse side. Signed X O a [�_6VTithe: -�'��h`r Date12 r- �Q EPARTMENT USE ONLY Application Accepted by /rA F DArea 0,5'rStk 466-6781 Additional Comments: Amk &942E - Lodi 369-3621 Vaso fit-u, MTutt Inspection b Date 1:P --t rd � Manteca 823-7104 Final Inspection by Date -7—�--�6--fl? Tracy 835-63$5 ..� Applicant - Return all copies to: nvironmental Health,Permit/5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk.;'CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED J RECEIVED BY DAT PERMIT NO. INFO EH 13-24 REV. 10/82 r T 10/82 500 14-2 6