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APPLICATION FOR PERMIT 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 (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. Job Address JroR ZAAfteY Al .7Ytcy Subdivision NameQ- Owner's Name ,GOON G" GUIf _iw Address l-.-y J ail?er S.,?. R.C, Phone Contractor's Name ;AA,,r/jpyy leSP .- License No. yyf0oA'fr,/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation F—IDomestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ' ❑Other ❑ Delta Type of Casing Lj Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 41 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [) Depth Size 9`X/O`1J! .?f° Number SUMPS Distance to nearest: Well Foundation .7 0' Property Line /0,4 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed egent'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." 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 applicant t call o all required inspections. Complete drawing on reverse side. Signed X t Title: Date: FOR DEPA KENT USE ONLY Application Ac�ted Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection byS, Date 222,,V-ZZ ❑ Tracy 835-6385 Applicant - Return all copies to: VvironmeWal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 8 S AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I 7d 5111 0_ EH 13-24 REV. 10/82 10/82 500 14-26