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APPLICATION FOR PERIAIT L[CAT I SAN JOAQUIN LOCAL.HEALTH DISTRICT �3 PERMIT NO. /,o I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 : ; DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (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 welt/pump and the Rules and Regulations of the San Joaou ocal Health District.. Job Address Subdivision Name Owner's Name �^r y / Address d 77 .4 � " '�(' Phone �� (• J Contractor's Name License No. e�y�iu "hone �� _ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION G PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER wc..LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ Industrial L]Open Bottom []Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack [J Tracy Dia. of Well Casing ❑ Public L10ther ❑Delta I Type of Casing — Irrigation Approx. ❑Eastern r Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout s t U Other -Y Surface Seal Installed by Repair Work Done L) Type of Pump H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADOiTION F! 'No septic tank or seepage pit permitted if public sewer is f available within 200 feet.) Installation will serve: Residence ��Commercial _ Other i Number of living units: 1� Number of bedrooms L Lot size Water table depth Character of soil to a depth of 3 feet: d � SEPTIC TANK � [� Type/Mfg C Capacity /.Z w No. Compartments 'L PKG. TREATMENT PLT.-C] Type/Mfg t:' tl Capacity Method of Disposal alt a Property Line �— _.�_— foundation SEWAGE SYSTEM � Distance to nearest: Well � �a.-- _ DESTRUCTION -- LEACHING LINE '" No. & Length'of lines r{ 40 Total length/size O r F• FILTER BED ❑ Distance to nearest: Well . I Foundation Property Line r - Number f SEEPAGE PITS Depth , Size ! SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �, r =-- *^- �* f I hereby certify that I have prepared this application. and that.the work will be done in accordance with San Joaquin county j ordinances, state laws, and-rules and regulations of^the San-Joaquin Local Health District. f Home owner or licensed agent's signature certifies the follbwing: "T`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 lawthe 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 shal em toy persons aubjQct to workman's'compensation laws of California." The appli t m t�ca for quired-inspections. Complete drawing an reverse side. Date: 140010 s Signed 41).- Title: I1 ALL_ k FOR DEPARTMENT USE ONLY � RLodi Stk 466-6781 pplication Accepted'by Area 0-1 369-3621 Additional Comments: h _ ❑ Manteca 823-7104 Pit or Grout Inspection ' Tracy�- Date Tcy 835-6385 Final Inspection by �� Date ❑ f Applicant - Return all copies to: Environmental Health Permit/Services 16 1 E. P�-1 Ave., P.O. Box 20D9, Stk., CA 95201 rFE BASE AMOUNT DUE AMOUNT REMITTED. RECEIVED BY DATE PERMIT NO. 1 O •� y S � a-� � $�' c�� . f I 1D/82 500 EH 13-24 REV, 10/82 14-26 i