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APPLICATION FOR PERMIT SAN JOAQUIN' LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3^ 76 Telephone (209) 466-6781 DATE ISSUED ¢ PERMIT EXPIRES I 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 Re ulations of the San Joaquin Local Health District. ,lob Address yd � 51 A�4,1?z �ly�/taubdivision Name Owner's Name / Address one Contractor's Name a License No Phone .� 5 TYPE OF WELL/PUMP WORK: NEW WELL g4---WELL REPLACEMENT DESTRUCTION �'' '-0 _ I, PUMP INSTALLATION n SYSTEM REPAIR f OTHER U ,; W DISTANCE TO NEAREST: SEPTIC TANK v -T SEWER LINES p`Z S DISPOSAL FED, PROP. LINE /4-6 FOUNDATION AGRICULTURE WELL 22Z 47a OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .� J Industrial F�en Bottom ❑ Manteca Dia, of Well Excavation / O> mestic/Private Gravel Pack [] Tracy Dia. of Well Casing Public �j Other Delta Li Type of Casing Irrigation Appro Specifications �� Fl✓ � Cathodic ProtectioGeophysical �n76u,,��__ - w Depth of Grout Seal _ ype of Grout UOtherx ' --";' urface Seal Installed byRepair Work Done F-1Type State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') I v TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or'`seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal Y SEWAGE SYSTEM ci Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE [J No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS IJ Distance to nearest: Well Foundation Property Line 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 workforwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman5 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 applicantorgrtl 11 for all required ins ec Complete drawing on reverse side. _ Signed X rG-d�, c�r. Title: �%�.f f* Date: 2xlzS FOR DEPARTMENT USE ONLY Q ' lD/'fj Application Accepted by � n� Area v ® Stk 466-6781 Additional Comments: v- Lodi ' 369-3621 Pit or Grout Inspection by Date _, Manteca 823-7104 C 5/ Final Inspection by Date 7_e 3 Tracy 835-6385 5 A plicant - Return all copies to: ironmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ;Rl_IT NO. INFO � � � 1� 0� � a� �CB�/��pSli"k EH 13-24 REV. 10/82 (_ 10/82 500 6j3 �7/, 14-26 ?" t D