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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 C9� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 4��s (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 Re tia s of the San Joq in �c"all Health District, Job Address 7-7 (t6 - bdivision Name � Owner's Name Address 11QOne 1 `z Contractor's Nam cG License No. Phone (cif -5[0 ty TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �f PUMP INSTALLATION (] SYSTEM REPAIR OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �t j� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial U Open Bottom Manteca Dia. of Well Excavation i U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing t ❑ Public ❑ Other Delta Irrigation ❑ Type of Casing Approx. 1 V 9 . Eastern Specifications s ❑Cathodic Protection Depth 1 Depth of Grout Seal i 1-1 Geophysical Type of Grout U Other - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ -Well Diameter Sealing Material (tap 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is f� 1. ,., available within 200 feet.) installation will serve: Residence _ Commercial Other 1I Number of living units: Number of rooms Lot size Character of soil to a depth of 3 Water table depth SEPTIC TANK Type/Mfg �No. Compartments ��C1 r PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation i(�z Property Line DESTRUCTION {� LEACHING LINE:, `Nv. & Length of lines Total lyngth/size JF ;10 E� FILTER B '^' Distance to nearest: Well Foundation Ze2Property Line ' SEEPAGE PITS Depth f Size Number, i SUMPS U Distance to nearest: Well Foundation Property Line �5 DISPOSAL PONDS ❑ 1 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 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'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." - R-* --GontracEor=-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 3aws'of California." The appl)ca must ca 1 f all required inspections. Complete drawing`on' everse side., , Signed x ` Title:.-, Y Date: L� U FOR DEPARTMENT USE ONLY dv Appl i ation'-Accepted by —Area 0� ____ ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date �y g %—� Manteca 823-7104 Final Inspection by Date Z�T 65 ❑ Tracy 835-6385 Appl-icant,- Return-all copie _to:-. Envi onmenta Health Permit/Services 1601^E. Haze ton Ave., P.O. Box 2009,�Stk', CA 95201 _ FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED-BY DATE PERMIT N0. INFO -_ _ r �3�109 EH 13-24 REV. 10/82 10/82 500 14-26