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,r APPLICATION FOR PERMIT x. SAN JOAQUIN LOCAL HEALTH DISTRICT - - 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT E%FIRES 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 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. Job Address r 6114/1� Z Subdivision Name Owner's Name - _ er�o,,•i..a,� �rg`ss 2 d Z Al Phone .�T a+r �Z�l ',rte_ Contractor's Name 7FSO&T License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT -❑ ESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑Delta ❑ ❑Irrigation Approx. Eastern Type of Casing 9 Depth Specifications ❑Cathodic Protection P Depth of Grout Seal ❑Geophysical Type of Grout 1-1 Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') y n Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (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: A/,i Number of bedrooms Lot size X'u x Z Id / Character of soil to a depth of 3 feet: e -4 y _ Water table depth SEPTIC TANKType/Mfg _ /'�f fF Capacity 1,6 11 e No. Compartments .t PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well .YC r Foundation Property Line -t DESTRUCTION ❑ LEACHING LINE No. & Length of lines a Total length/size /7 l FILTER BED Distance to nearest: Well p - Foundation- f ❑ ( j��j Property Line SEEPAGE PITS Depth :2,f'� Size Number SUMPS Distance to nearest: Well s Foundation U /d"d' _.9;iµ Property Line l,~ 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.-.wor_kmant 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 Mt call for a_1] r quir�d_ipections. Complete drawin.gron reverse side. Signed X /�� ? Title: r Date: OR DEPARTMENT USE ONLY Application Accepted by 611/1! Ae, - -�j�- Area 2-Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by v - Date — S`'�� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1101 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED `'� 'RECEIVED BY DATE PERMIT NO. INFO -3 : 4 EH 13-24 REV. 10/82 10/82 500 14-26