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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6751 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.in Triplicate) PERMIT N0. 1j DATE ISSUED S''1 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 compliarce 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 3 <,c?/p �,_� � �/��j% �5subdivision Name Owner's Name / f '!j/S �. j -/Q,E� Address ��/�. ��JSi/�!�?C PS �1Fj,( I 'w Phone WA3r^7 %7 TW9 Contractor's Name isoc�c° License No. -%l Phone3p`+—/i�yy� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOJNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 17 Industrial ❑ Open Bottom U Domestic/Private ❑ Gravel Pack ❑ Public ❑ Other F, Irrigation Approx. ❑ Cathodic Protection Depth ❑ Geophysical U Other Repair Work Done ❑ Type of Pump Well Destruction U Well Diameter Depth PROBLEM AREA ❑ Manteca ❑ Tracy ❑ Delta Type of Casing Eastern Specifications Depth of Grout Seal Type of Grout Surface Seal Installed by _ H.P. State Work Done _ Sealing Material (top 509 Filler Material (Below 50') CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing TYPE OF SEPTIC WORK: NEW INSTALLATION }❑ REPAIR/ADDITION IM (No septic tank or seepage pit permitted if public sewer is available within 200 feet.). Installation will serve: Residence X_ Commercial Other p T` X A /I Number of living units: I Number of bedrooms Lot size SEEPAGE PITS Character of soil to a depth of 3 feet: S *,y 'we, Water table depth SEPTIC TANK ❑ Type/Mfg DISPOSAL PONDS Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Q Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE [ j No, & Length of lines % - //o 6f Total length/size p T` X A /I FILTER BED ❑ Distance to nearest: Well ,5'Cbtndation / ft Property Line SEEPAGE PITS ❑ Depth / Size �2 Number i SUMPS U Distance to nearest: Well 147 G Foundation J,(9— Property Line ao 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§ 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 Aust call forjill required inspections. Complete drawing on reverse side. Signed X .(��. j," Title: C�co4'Ar Date: F DEPARTMENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 364-3621 Pit or Grout Inspection by Date Manteca 823-1104 Final Inspection by NE CrLw% Date Tracy 835-6385 Applicant - Return all copies t� Environmental—Aalth Permit/Services 1501 E. Hazelton Ave., P.Q. Box 2009, Stk., CA FEE _ BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 7=1� `-"3 95201 EH 13-24 REV. 10/82 10/82 500 14-26