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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA 'PERMIT NO. Telephone (209) 466-6761 DATE ISSUED PERMIT EXPIRES 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_� p ..r 1 i Subdivision Name Owner's Name I" Address Phone s Contractor's Name oc3r'�2+TC> L ' License No.` S�f�T��' �" Phone r ?: -TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION Cf PUMP INSTALLATION SYSTEM REPAIR OTHER Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOtS _ 1-1 Industrial tc Q Open Bottom E]Manteca Dia. of Well Excavation i L_IDomestic/Private Gravel Pack Tracy'' Dia. of Well Casing ' Public Other []Delta Type of Casing F (J Irrigation- Approx. Eastern fit• f Cathodic•Protection Depth . �; t !~ Specifications, Geophysical;•. , y Oepth;bf Grout Seal f t Type of Grout ' Other ' SJr*face Seal Installed by Repair Work Done Type of Pump H.P. t State�Work Done ~� Well Destruction F-1 Well Diameter Sealing Material (top 50 1) x _ Depth Filler Material (Bel ow 50,)tLU l TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION u' (No septic-tank or seepage pit permitted if public sewer is t ► available within 200 feet.) Installation will serve: Residence Commercial . Other,. } Number of living units: _ Number of bedrooms f-3, `�Lotlsize ,�. Character of soil to a depth of 3 feet: I % • - Water table depth SEPTIC TANK Type/Mfg la ' Capes acity z INo. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal i SEWAGE SYSTEM Distance to nearest: Well foundatign -lam Property Line `s 1} DESTRUCTION ❑ .. 1• . ,. '+. '. a } LEACHING LINE No. '& Length,of lines. ^ L/ Total length/size,• ? FILTER BED Zistance-to'nearest:4 Well :Foundation Property Line., f SEEPAGE PITS Depth _ 916*' Size.— Number SUMPS L_J-.-Distance to.nearest: Well /r-T;&ndation 6'y4' Property Line 0292 4' DISPOSAL PONOS. (].. '" ` V , I•hefidti rtify that I have`iprepared this application and that the work will bedoneiri accordance with San Joaquin county ordinances, state laws, and rules and regulationsofthe San Joaquin.l.4cal health"Dis`trict. - Home Owner or licensed agent;s signature certifies-the.foliowing: "I certify that,in the perforMance of the work-for which this permit is issued, I shall not.employ any person inNucb:'rt nrier�as to become subject to workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foll.ow)ng: ":'I certify that in the performance of the work for which 4 this permit is issued. I shall employ persons subject to workman's co6px2nsation laws of California." fThe applicant must call fo all required inspections. .Complete drawing on reverse side. Signed % /��yyiG "V '" ..,, Title: -.-.. Date:. ' OR D TM U NLY Application Accepted b Area Stk 466-6781 Additional Comments: 369-3621 Pit or Grout Inspection -- A :-� f ate 6 Manteca 823-7104 Final Inspection by ' Date Q P.O*Tracy 835-6385 a Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:', . Box 2009, Stk., CA 'x95201 -- -FEE, -8ASE_—AMOSIN.T,DUE--. :�31-AMGUNT-REMITTED- --RECE,IAO--BY---- - DATE• ,-- PERMIT NO.- INFO, O.-INFO' �'- wI-S 1_ EH 13-24 REV. 10/82 ` f0/82,500 `+ 14-26 :i. ..