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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) ' Application is hereby made io 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 San Joaquin Local Healt Di rict. Job Address �c� t J uhdi ision Name Owner's Name lass 5' , Phone Contractor's Name ''F ,�o l�if Utr[--�Z- ../�cc� License No, 245Phone TYPE OF WELL/PUMP WORK: 1p NEW WELL WELL REPLACEMENT DESTRUCTION 'k� I PUMP INSTALLATION SYSTEM REPAIR OTHER I ' DISTANCE TO NEAREST: SEPTIC TANK .��1 ,}-_ SEWER LINESt4- 11 S6 DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE II TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o k I Industrialepi f] Open Bottom � Manteca Dia. of Well Excavation ! f Domestic/Private IJ Gravel Pack �{ Tracy Dia. of Well Casing PublicOther Delta Irrigation ry'I Type of Casing let/C L� Approx, E] Eastern ' - bSpecifications [ICathodic Protection , Depth . Geophysical - �� w.. Depth of Grout,Seal, ?' Type of Grout Other Surface Seal Installed byAll Repair Work Done D Type ofPump H.P. �j� State Work Done Well Destruction Well Diameter Sealing Material (top 50') ' �Ylw > �" Depth �I Filler Material (Below 50') Oro, r 1 IV, F ° F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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: 4�r•. Water table depth SEPTIC TANK Type/Mfg Capacity + x Na. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity k Method of Disposal y SEWAGE SYSTEM ��----II Distance to nearest: WeIIFoundation Property Line i DESTRUCTION k. r LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Welli Foundation Property Line dd SEEPAGE PITS Cj Depth Size, Number SUMPS U Distance to nearest: well! Foundation Property Line # F f DISPOSAL PONDS CI E I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I ordinances, state ws, and!lrules and regulations of#the San Joaquin Local Health District. # :h Home owner or li ens agent's ignatur certifies the following: "I certify that in the performance of the work for which this £ permit is issue ,I s all not m loy a y erson n such manner as to become subject to workmant compensation laws of California." Contractor's hi ing r su -con ra ting si natu e certifies the followings "I certify that-in the performance of-the work forwhich this permit is i su d `all em oy pe o subject to workman's compensation laws of California." _ The applicant m 11 fo �a u' i tions. Complete drawing on reverse side. Signed X I Title: Date: R DEPA TMENT USE ONLY Application Accepted by Area 01g [� Stk 466-67$1 ! Additional Comments:i Lodi 369-3621 / �Cj/-04 Pit or Grout Inspection by r Ott e ja2f4 Date 7— Manteca 823-7104 J (J Final Inspection by 1i1 /W5 i-Date � Tracy 835-6385 �° f Applicant,- Return all copie o• nvironmental Health Permit/Services 1601 E. Hazelton P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10 0 7—«Pi EH 13-24 REV. 10/82 _ 10/82 500 14-26 �� (/-CU In/'�'�"®' a