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APPLICATION FCR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. = Telephone (209) 466-67$1 } DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED ' (Complete in Triplicate) ++ i 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 r and the Rules and Regulations of.the San Joaquin Local Health District. r Job Address ! � JV` JC_cG-.K /j e. Subdivision Name ( P �ly H/�L1(SrAddress) , -Rena !`+�.5 — 0'J'o Phone Owner's Name . (�7� € i Contractor's Name 1C �/� License No. l 2 Phone �� r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U { r + PUMP INSTALLATION•0 SYSTEM REPAIR EJ OTHER U i " � a Aye PROP. LINE !� DISTANCE TO'NE'AREST: SEPTIC TANK_ SEWER LINES, /vim �. DISPOSAL.-FLD. lU� __ FOUNDATION �� AGRICULTURE WELL /II )I i— OTHER WELL Taft PITS/SUMPS /�/ /`J+� �. INTENDED USE T TY7E OF WELL PROBLEM AREA A r CONSTRUCTION SPECIFICATIONS r` I l Industrial jgOpen Bottom Manteca Dia. of Well Excavation — Domestic/Private Gravel Pack Tracy r Dia. of Well Casing k Public Other L] Delta Type of Casing ,, ❑ irrigation �� Approx. C] Eastern+ Specifications ❑Cathodic Protection Depth s ff Depth of Grout Sear p k ❑ Geophysical Type of Gr F122 U Other e al Insta surface seed y- rr- E Repair Work Done Type of Pump H.P, ") State Work Done Well Destruction ❑ Well Diameter ; Sealing Material {top 50') ! — [ Depth Filler Material (Below 50') *; y _ r TY.P.ErOF,rSEPTIC WORK: -NEWLA R PcAIR/ADDITTIONJ-U�(Nc. septic tank or seepage7p,i't'rpermitted if public sewer is available within 200 feet.) E Installation will serve: Residence Commercial Other * . " £ *• ...„.�.. _ �- ... .. i' Number of living units: Number of bedrooms Lot size �- Water table depth y Character of soil to a 'depth of 3 feet: ~ r""` SEPTIC TANK Type/Mfg Capacity No. Compartments x r PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal 11 SEWAGE SYSTEM � Distance to nearest: Well Foundation Property Line LJ � DESTRUCTION 4 LEACHING LINE [J No. & Length of lines Total length/size M FILTER BED- Distance to Well Foundation Property Line Depth Size :Number Y SEEPAGE PITS .�- ._. ,�_-_ — --_. SUMPS ~LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I � x• 'i. I hereby certify, that I have prepared.-this application and that the work will be done in accordance with San Joaquin county f ' ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. work for whichthis Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the ` --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 issued, I shall employ persons subject to workman's compensation laws of California." ! The applica must c/a/ll f/or al] required inspections. Complete drawing on reverse side. Y I Signed X /Lsi Title: Cd— Signed T FO EPRRTMENT USE ONLY Area Stk_ 466-6781 Application Accepted by Lodi 369-3621 Additional Comments: Dat Manteca 823-7104 Pit o out nspection Date L Tracy 835-5385 Final Inspection by - Applicant - Return all copie to: Enviro men 1 Health Permit/Services I60 E. azelton Rve., P.O. Bax 2009, St k., CA 95201 PERMIT NO. . FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ((�� INFO 3— [6-� EH 13-24 REV, 10/82 Pal 10/82 500 14-26