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APPLICATION FOR.PERIIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON,' CA PERMIT NO. Telephone (209) 466-6781 " - � GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made to the Sari 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 4 and:the Rules and Regulations f t San Joaquin Local Health District. Job Address 30 Subdivision Name �" /�.l Owner's Name Address Phone••�•� Contractor's Name License No . 6,y2. .-/ Phone 3 3f-3 3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ O� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Gj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (J`1 17 Industrial U Open Bottom ❑Manteca Dia. of Well Excavation C F-1 Domestic/Private Gravel Pack f_1Tracy Dia. of Well -casing ❑Public [.Other ❑Delta Type of Casing" Irrigation Approx. ❑Eastern Specifications-: ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by ' Repair Work Done 0 Type of Pump, H.P. State Work Done Well Destruction �J Well Diameter Sealing Material',A(top 50') - G} Depth ' -Filler Material (Below 501 O TYPE OF SEPTIC WORK: NEW INSTALLATION L�REPAIRIADDITION ,U (No septic tank or seepage pit permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence 40 Commercial Other T _ i Number of living units: —L-i Number of bedrooms' Lot size Character of soil to a depth ofi3 feet: Water table depth ZV SEPTIC TANK ❑+r Type/Mfg -. ''- ,.Capacity j cy No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg r Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest:Weli �_ Foundation �(7 ..•..•Property Line DESTRUCTION I LEACHING LINE No. & Length of lines Total length/siie. r -- FILTER BED [a3. Distance to nearest; Well Yo. Foundation Property. Line%�. 10 _ f 1 SEEPAGE PITS Depth Size Number y SUMPS L Distance to nearest: Wel} Q Foundation Property Line �� 1 DISPOSAL PONDS t i � R I hereby certify that I have prepared this application and tfnat�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 ds to become subject to workman9 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 mu all fo a wired inspections. Complete drawing on reverse side. 0 r �� Signed X ' Title: &(,{/La Date: n FOR DEPARTMENT USE LY Application Accepted by r�. Area- �^^- `-r-E]"'Stk -466-6781 Additional Comments: , 1 Lodi 369-3621 Pit or Grout Inspection by Date I ❑ Manteca 823-7104 Final Inspection by r^ Date � ❑ Tracy 835-6385 Applicant - Return all copie to:... Environmental alth Permit/Services,,1.601 E. Haze ton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT CUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ©, lJ , 1. 1?y �1� 20/82 500 EH 13-24 REV. 10/82 14-26