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v APPLICATION FOR PERMIT f 1f1 SAN JOAQUIN LOCAL HEALTH DISTRICT 3 ^ / Q �.v 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, j, 0l�n(0 Telephone (209) 466-6781 DATE ISSUED 5 1 I f 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 ` (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 a and the Rules and Regulations of the anJ quin cal Health District, Job Address Subdivision.Name Owner's Name �/1"�w A l2 1 �c"rE`-AddressZ7 Phone Contractor's Name /_Fi'�=License No. 7 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIRS lJ OTHER ❑ (r3 DISTANCE TO NEAREST_: SEPTIC TANK SEWER LINES DISPOSAL FLQ. _ PROP. LINE 1 FOUNDATION _/D AGRICULTURE WELL *"�� OTHER WELL PITS/SOWS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATiQNS f 10 ❑Industrial - Open Bottom ❑Manteca Dia. of Well Excavation f 17Domestic/Private ❑Gravel Pack [1 Tracy Dia. of Well Casing k ❑ Public ❑Other ❑Delta Type of Casing i Irrigation w, A rox. ,, L- 9 ep Specif ications _ Cathodic Protection Depth =- Depth of Grout Seal + ❑Ceophysical Type of Grout OtherSurface Seal Installed by Repair Work Done E] Type Type of Pump ,_ State Work Done --- Well Destruction l.J Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') �11 TYPE OF SEPTIC WORK: NEW INSTALLATION (,� REPAIR/ADD,TION (No septic tank or seepage pit permitted if public sewn is available within 200 feet.} Installation will serve: Residence Commercial Other G _ N er of bedrooms .s3 Lot size _'� Number of living units: � ° e Character of soil to a depth of 3 feet: _�p �iJ4 - Water table depth � 1 i� a. No. 1 SEPTIC TANK � Type/Mfg �L ''r L _�_ Ca ��rre� Compartments PKG. TREATMENT PLT. ❑ Type/Mfg i.� Capacity Method of Disposal Septic Tank Distance to nearest: Well L&0� ' Foundation ��PropertyILine I c rice inn.' �i 4 6� F total length/size i i LEACHING LINE � Na. & length of lines .. ��_ d — FILTER BED ❑ Distance to nearest: Well Foundation Property,Line e SEEPAGE PITS ❑ Depth ize Number SUMPS ❑� Distance to nearest: Well Foundation i 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 orainances, state laws, and rules and regulations oC 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 als-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 for- -+require inspections_ Cnmplete drawing on reverse Side. x_47, _t Date: �_ Signed X Title: _�e�.i-- �_ �EP MENT USE ONLY Application Accepted by Area ❑ Std 466- Additional Conts: �_ ❑ Lodi 369-3362621 1 mme Pit or Grout Inspection by Date [� Manteca 823-7104 Final Inspection by _ Date ❑ Tracy 835-6385 Applicant Return all copies to: Environmental h Permit/Services1 O1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY. DATE PERMIT N0. _ INFO �3 10/82 500 E-i 13-24 REV. 10/82 14-26 w