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APPLICATION FOR PERMIT' Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. STOCKTON; CA PERMIT NO, Telephone (209)466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —fi (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. 4 . " Job Address ,� °' '� Subdivision Name P. Owner's Name Address Phone V,GLi— OjK i Z� Contractor's Name .. License No., ?j" "fit `� Phone �iXGC -= 067 - TYPE;OF WELL/PUMP WORK: NEW WELL �] M WELL REPLACEMENT��[:] DESTRUCTION E �11MPFINSTALLATION �] SYSTEM REPAIR ❑ OTFIER"Q�' DISTANCE TO NEAREST: SEPTIC-TANKk SEWER LINES DISPOSAL FLD. PROP, LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED-USE 51- TYPE,O -WELL -" PROBLEM AREA CONSTRUCTION SPECIFICATIONS F111* Open Bottom ❑Manteca , Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy' Diii-lof_Well Casing r' Public ; - ( ❑ Other Delta c Irri, ation-^ Type,}of Casing "v L_I g Approx. El Eastern ; i� Oe th Specifications[]Cathodic Protection �--..-.-�,.-p. Specifications k f �^- Depth of Grout Seal D"Geophpsica1 k LJ Other TYPe-of—Grout ./ N1- z. Surface Seal Installed by Repair Work ,Done �] Type of Pump H.P. State Work Done ' r Well Destruction ❑ Well Diameter Seating Material (top 501) � ' Depth Filler Material (Below 501) f''"T_YPE OF.SEPT ICs WORK: NEW°INSTALL'ATION U REPAIR/ADDITION U (o septic tank al- seepage,pit permitted if public sewer i' J �T available within 200 feet.) Installation wi91 serve: Residence f-{Commercial`=� Other i l Number of living units: .Number of bedrooms : Lot size r4 14&4% *+� __. i Character of soil to a depth of 3 jf Water,table depth t;0 feet: ��r_ SEPTIC TANK Lj Type/Mfg Capacity No. (Compartments\. PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal 9. y SEWAGE SYSTEM Distance to nearest: Well Foundation Property'Line DESTRUCTION . ❑ LEACHING LINE, �% f No. & Length of lines Total length/size t t FILTER BED w` Distance to nearest: Well Foundation Property Line t4 SEEPAGE PITS Depth. 3 p I size'.a,.A. '�" Number SUMPS LJ , Distance to nearest: Well Foundation _Vp ` Property Line, 4.F, 1 DISPOSAL PONDS f 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 rules and regulations of the San Joaquin Local Health District, % k f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-the work for which this i permit is.issued, I shall not employ any person in such manner as to become subject to workmant compensation.laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cert-ify 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." fThe applica ust call for all required inspections. Complete drawing'on reverse side, i . Signed'X Title; 'Date: d7 ! ,. PARTMENT USE LY 7 ,Application Accepted by ""` ,Area �C�z. (f.2 �'�Stk 46686_81 Additional Comments: ! �` ' �- � Lodi 369-3621 , Pit;or Grout Inspection { Date ❑ Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 + s --Applicant---Return-all copi : EL .n vi onmental Health Permit/Services 1601 E. Ha el It Ave., P.O. Box 2009, Stk., CA 95201 w FEE BASE r AMOUNT DUE RMDUNT REMITTED RECEIVED"BY DATE , PERMIT N0, }" INFO, EH 13-24 REV. 10182 10/82 500 I