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, 4 tD APPLICATION FOR PERMIT SAN' JOAQUi!! LOCAL HEALTH DISTRICT 1501 E. HAGELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209} 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED GATE 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 Regulations of. the San Joaquin Local Health District, Job Address � R-2> ,Subdivision Name Owner's Name f�,q � -- Address S Phone Contractor's Name ��. ie,52> License Na. _47-4<2-71, Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ y--5Y5TfM+REPA3R— --{1TIifR � �, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. rl` PROP. LINE I FOUNDATION i AGRICULTURE WELL OTHER WELL i PITS/SUMPS f , INTENDED USE TYPE OF WELLF PROBLEM AREA CONSTRUCTION SPECIFICATIONS j Industrial UOpen Botto�m Manteca Dia. of Well Excavation, l � + ❑ Domestic/Private ❑ Gravel Pack ❑(Tracy Dia, of Well Casing ` ❑ Public ❑ Other d Q,Delta:. !e �. 4 3 ? Irrigation ! � .. ' . : .i /Type,of Casing L i g Approx, ❑ Eastern ; ° Q ` 6 ❑Cathodic Protection ' `"� "Depth Specifications `� { ❑ pthvof Groat Seal Geophysical i { "4; P ' is Other Type,of Grout � /� .x 5��. // ;vt, +`� Surface Seal Installed by Repair Work Done ❑ Type of Pump/ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50' Depth f Filler Material (Below 50') 9 TYPE OF SEPTIC WORK:/ NEW INSTALLATION �/ REPAIR ADDITION '" _ f y L"f / I J (No septic tank ar seepa.ge pit permitted 'if pu61-ic sewer is available within 200 feet.) Installation wi,I`1' serve: Residence _� Commercial Other .�'�;�„�� Number of 1 iving�units: __1-_ Number of bedrooms '7��,• Loot size-, Character of soil a�depth of 3 feet; e 4 AJ1 YWater table depth sl!. SEPTIC TANK �. ` fiYpk f9 CC Og=L Capacity app I.No. Compartments PKG. TREATMENT PLT, ❑ Type/Mfg ( Capacity ;Method of Disposal i SEWAGE SYSTEM Distance t nearest: Well j 0 FoundatioProperty Line S� f� DESTRUCTION Fl -- 7 t F V LEACHING LINE No, & Length of les 1067 Total- length/size FILTER BED Distance to nearest: Well ❑ �uE1' FoundationQ ` Property Line SEEPAGE PITS Depth �(� Number',: ` / '♦ SUMPS ❑ Distance to nearest: Well /0Q"f Foundation /01? Property Line F DISPOSAL PONDS ❑ " "'" I hereby certify that I have prepared this application and that the work will be done in ace'ordance with San Joaquin county f .` 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 ;perfo"rmance of the_work_for which--this— permi,£ is issued, I shaII not-empl'69'a7y person in such manner as to become subjec1No woi'kma'nt compensation laws of California'." Contractor's hiringlo"r sub-contracting signature certifies the following: "I certify that i.n'the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation lawsfof,Cal-fornia." The applicant must call for all required inspections. Complete drawi reverse side Signed X -y� Title: _ Date: r f J FOR DEPARTMENT USE ONLY Application Accepted by Area ' Stk466-6781 a Additional Comments: az, AP Lodi 369-3621 Pit or Grout Inspection by Date �` -� a Manteca 823-71044 Final Inspection by Date �- 7 ❑ Tracy 835-6385 , { Applicant - Return all copies to Environme 1 Health Permit/Services 1601 F. Hazeltor PM., P,O, Boz 2009, Stk., CA 95201 S FEL BASE AMOUNT DUE: AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO If JILI S a -S9 EH 13-24 REV. 10/82 10/82 500 14-26 i