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1 — +.i APPLICATION FOR PERMIT +f'" SAN JOAQ6iN LOCAL HEALTH D SYRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��—Lit Li Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED. - 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 RegulatioLbof the San Joaquin Local Health District.. Job Address j,A7Subdivision,Name " Owner's Name ' kFoV e.&reC# Address O 5_1 j Y 4 61 Phone Contractor's Name 1 - ', License No. _5,9P Phone -.29 9/x-31 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U ;-DISTANCETO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL HLD, PROP. LINE i — >. FOUNDATION AGRICULTURE WELL OTHER "TELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA' "' ONS TRUCTION SPECIFICATIONS` p ❑ Industrial U Open Bottom Manteca Dia.-of Well Excavation U Domestic/Private Q'Gravel' Pack �i�'Tracy (Dia. of Well Casing ' Publ is Lj'Other [] Del to - _ LjlrrigationType of Casing ! , Approx. Eastern CathodicProtection Depth Spe cations c� , LJ Geophys"lead•, Depth;'of Grout Seal =` U Other r . .» 5 i! 'Type-of-Grout : / -,• iA Surface Seal Installed by i Repair Work bone Type of Pump w H.P, State Work Dane �y«" rb Well Destruction U'` Well; Diameter '; Se ling Material{top 50'-) r. �- Depth _ Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION No septic tank or seepage pit permitted if public, sewer is � U k(r available within 200 feet.) Installation will serve: :Residence _ Commercial Other r " Number of li.vi4g units-, Number of bedrooms t Lot size Character of soil to a depth of 3 feet: !j Water table depth _ `T SEPTIC,TANK -- i Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. Typo/Mfg Capacity Method of Disposal' SEWAGE,5YS7EM Distance to nearest: Well Foundation r7- Propert 's F7-- DESTRUCTION U � y tine1�"Q LEACHING-LINE No. &'Length of lines T Total length/size g `T erp FT FILTER;BED - Distance to nearest, Well4 - fi[[D Foundation F 7- Property Line PAGE"PITS Cj Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line OISPOSRL 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;haws., and rules and regulations of the'San Joaquin Local Health District. Home owner or licensed agent's signature ce'rti'fies-the'followin'g: "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 issuedl'-f issued,'-fshall employ persons subject to workman's compensation laws of California." y The applicant must cal for: 11 required inspections. Complete drawing on reverse side. Signed XTitle: k Date: Application Accepted by DEPARTMENT USE ONLY F R Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L� Manteca 823-7104 Final Inspection by Date 3r� ❑ Tracy 835-6385 i ,Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 j 3 FEE BASE AMOUNT DUE AMOUNT REMIRECEIVED BY DATE PERMIT NO. INFO TTED/' 1 - _ _' :: - "�, � { -• -r..-�. "- t;• - �' _.� � .., 771,J EH 13-24 REV. 10/82 10/82 500 i 14-26 i