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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT Lf 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. - b k, Telephone (209) 466-6781 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 /557 ,S 7 . AiROoczT Subdivision Name _ Owner's Name GARY QVI-PAIS Address Phone 3' / 56 Contractor's Namer`1 C".R6,Lc License No y.3/$ Phone 39^ 2126 TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 [—I Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing IA ❑ Public ❑Other ❑ Delta Type of Casing UJ Ljirrigation Approx. ❑ Eastern Specifications J Depth❑ Cathodic Protection Depth of Grout Seal I ❑Geophysical Type of Grout V Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') T TYPE OF SEPTIC WORK: NEW INSTALLATION ;K1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ►/ available within 200 feet.) A Installation will serve: Residence A Commercial — Other 1" Number of living units-:---/ Number of bedrooms 2 Lot size Character of soil to a depth of 3 feet: Water table depth 20 SEPTIC TANK Y Type/Mfg PR—e-e, Me T Capacity 2 0� Compartments 7 PKG. TREATMENT PLT. EJType/Mfg Capacity Method of Disposai �I}• SEWAGE SYSTEMDistance to nearest: Well 00* Foundation O Property Line /0i' DESTRUCTION ❑ LEACHING LINE LA No. & Length of lines 70Total length/size FILTER BED ❑ Distance to nearest: Well 00� Foundation /V z Property Line SEEPAGE PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Lire 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 workman!s 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 per ons subject to workman's compensation laws of California." The applicant m t call for all quire nspections. Complete drawing on reverse side. `�/,, /-�_ Qy signed X / Title: Datg; D'7 F EPARTMENT USE ONLY Application Accepted by Area -� Ej.Stk 4667.0il Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date $y ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 =� BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I 10/82 500 EH 13-24 REV. 10/82 �. 14-26