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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 BATE ISSUED 1ya v PERMIT EXPIRES I YEAR FROM DATE ISSUED t'i'-Y (Complete in Triplicate) I Application i hereby madeI�to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described. is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rul and Regulations of-the San Joaquin Local ealth District. [�/ J Job Address, —, Ik { PJoel. Subdivision. Name � ICL17. Qr�! 38' Owner's Name ��( (� ,a/�, Address �j,S[I ` fp_f/�Su�lT[iet [pled&g2 ,Phone e1Dj.2_V3-_46 5 16 y Contractor's Name License No. aQQ�/� Phone TYPE OF WELL/PUMP WORK: II NEW WELL WELL REPLACEMENT DESTRUCTION E PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK _�]�j{?e SEWER LINES DISPOSAL FLD. f70)1ej PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL np h i°s PITS/SUMPS Z INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l► Industrial ; U Open Bottom El Manteca Dia. of Well Excavation r� (Domestic/Private ravel Pack [] Tracy Dia. of Well Casing L� Public i 71 Other Delta Type of Casing Irrigation I Approx. Eastern Specifications Cathodic Protection II Depth ^ Depth of Grout SealLl _ �.zr•� GeophysicalFI i Type of Grout _��} Pi"fj/]u � Other I� Surface Seal Installed by ��`� �� Repair Work Done [J– Type of Pump N.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') DepthFiller Material (Below 50') n TYPE OF SEPTIC WORK: NEW ;:INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is — Iavailable within 200 feet.) Installation will serve: Residence Commercial Other Number of living units- 11 Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal i -Distance to nearest: Well Foundation Property Line 4 LEACHING LINE IJ No. & Length of lines Total length/size FILTER BED ❑ .Distance to nearest: Well Foundation Property Line SEEPAGE PITS C1 Depth Size Number SUMPS L_I 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS II 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. i 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 workmant 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 applemust call for all uired inspect ons. Comp ete aw'ng reverse side. _ Signed X w Title: � Date: `v �I 0• DEPARENT ONLY { Application Accepted by Area' �� [� Stk 466-6781 Additional Comments.: Lodi 369-3621 Pit or Grout Inspecn tion by DateAManteca 823-1104 ��t � Final Inspection by Date =''�►–r ❑ Tracy 835-6385 Applicant - Return all copies to: vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 it FEE BA E AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO } EH 13-24 REV. 10/82 �I 10/82 500 14-26 ly