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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT / 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ( �7c� Telephone (209) 466-6781 q DATE ISSUES] 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 ReggJulations of the San sf.JAoa)quin Local Health District. vi Job Address _ d)Z 4 A 20 P,JD Subdivision Name Owner's Name v Address O Mrd!/ one Contractor's Name A,J, CJ[ License No. �,� �it Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 J Industr'ia'l - -� ❑ Open Bottom` - ❑ Manteca -Well-;Excavation -•-w e Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing �^ ❑ Public ❑ Other, ❑ Delta Type of-Casing (❑ Irrigation Approx. ❑ Eastern Specifications` ❑ Cathodic Protection Depth � Depth of Grout Seal L7 Geophysical r' Type of Grout Other , Surface Seal Installed by I f Repair Work Done ❑ Typero.f'Pump/ H.P. State Work Done Well Destruction ❑ Wel rDiameter Sealing Material (top 50') Depth 3 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW- INSTALLATION,5( REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is k:k, r , available within 200 feet.) t Installation will serve: Residence commercial — Otherl G Number of living units: Number of bedrooms Lot size Character of soil to a depth of,3•feet: 641V RV 0 Water table depth ''Sim'^ No. Compartments b SEPTIC TANK Type/Mfg ` �i�ax�� _ Capacity l��tt1 PKG. TREATMENT PLT. Type/Mfg `�- W Capacity Method of. Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearesti.. Well Foundation Property Line- SEEPAGE PITS ❑j Depth size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IF hereby certify that I have prepared this application and that the work will be"done in accorilan6rwith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner dr 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 must call 91'r a 1 equired inspections. Complete drawing on reverse side. �7 Signed X I Title: Date: • OR DEP RTMENT USE ONLY ` ❑ Application Accepted ToyA Area tC Stk 4b6-67B1 'Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ( Manteca 823-7104 Final Inspection by Date /9� ❑ Tracy 835-6385 'Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201` 4 FEE BASE AMOUNTDUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. INFO � � L a� 3 Y3- 16 72 I EH 13`24 REV-10/82 1 �/ /�� 10/82 500 14126