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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICTG� a 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781' DATE ISSUED { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { Ll in Triplicate) �f ir�.5q �S� - �i ir.4-�.,� ,.pjz- a/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta l 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 He'06A DX rlct,� -Dw-- �t Job Address® 1�.7 lam- ' 141 ! as S++ubdiviisfioonn Name Owner's Name Address _ C Z0 Phone. `.Contractorps Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E] }/' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ C _� DISTANCE TO NEAREST:%SEP'TIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/�UMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ,�1 FJ Open Bottom ❑ Manteca Dia. of Well` Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing r Public ❑Other ❑ Delta Type of Casing Ej Irrigation Approx. ❑ Eastern Specifications ' ^� ❑Cathodic Protection Depth _ Depth of Grout Seal ❑Geophysical , Type of Grout ' L((Other- Surface Seal Installed by �- Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ - J -Y:PE�OF—SEP-TAC�WORK:=-NEWLINSTAlfLFP IO REPAIR/ADDITION No septic tank or seepage pit permitted if public.sewer is . - — � available within 200 feet.) (} Installation will serve: Residence Commercial Other LA Qk e Number of living units: Number of bedrooms ^Lot'size y 1 Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK Type/Mfg Capacity No. Compartments (� PKG. TREATMENT PLT. ❑ Type/Mf 9 Capacity Method of Disposal r�41 I; -`� Distance to nearest: Well Foundation Property Line `1 I LEACHING LINE ❑ No. & Length of lines Total length/size y s A e FILTER BED Distance to nearest: Well 1f�3 Foundation jet Property Line CZ SEEPAGE PITS [] Depth Size Number 1 SUMPS ❑ Distance to nearest: Well Foundation 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 ordinances, state laws, and rule`s and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature ertifies the following: "I certify that in the performance of the work for which this Perm i*sl,,hall not employ an erson in such manner as to become subject to workman§ compensation laws of.California." Contror sub-contracting gnature certifies the following: "I certify that in the performance of the work for which this d, I shall employ p sons subject to workman's compensation laws of California." The a0 1 re it imk ections. Comp ete on reverse side_ SignTitle: Date:FOR DEPARTMENT USE Yccepted yArea Q ® Stk 466-6781 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-710A- Final Inspection by /�'✓�� dalsd Date /2-/444 z. ❑ Tracy 835-6385 Applicant - Return all copies to' Environmental Health rmit/Services 1601 E. Hazelton Av ., P.O. Box 2009, St k., CA 95201 .4 t FEE BASE AMOUNT JIDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Wa R �I ICj 10/82 500 EH 13-24 REV. 10/82 , �. 14-26