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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ( 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. O S 1 j 16 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 A !// 4,4 Re roc% Subdivision Name S, J• A C, Owner's Name 4,e,4 v ,ir, Address .Z0,pop )YA55on, Phone Contractor's Name ,ogr&rylyy Pe SoH License No. Phone 5".t�'�/�/ U' 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 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑Open Bottom Manteca Dia. of Well Excavation 1-1 Domestic/Private r_1 Gravel Pack E] Tracy Dia. of Well Casing 1-1 Public F-1 Other 0 Delta LjIrrigation Approx. Eastern Type of Casing (J Depth Specifications Cathodic Protection P Depth of Grout Seal 17 Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence / Commercial _ Other available within 200 feet.) O Number of living units: _/_ Number of bedrooms — Lot size ,6`0'q'/00 ' CJ Character of soil to a depth of 3 feet: G 4 DAit9 Water table depth /0 ' SEPTIC TANK EJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well . Foundation "740-d- Property Line LEACHING LINE [J- No. & Length of lines Total length/size FILTER BED LZ Distance to nearest: Well Now,-z_/Foundation /0 e Property Line S SEEPAGE PITS F—j Depth Size Number SUMPS IJ Distance to nearest: Well Foundation Property Line 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 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." 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 mu call for all required inspections. Complete drawing on reverse side. Signed X Title: Dater ✓5`� SJ DEPARTMENT USE ONLY Application Accepted by FV_ �/ tArea o 7 E] Stk 466-6781 Additional Comments: M Lodi 369-3621 Pit or Grout Inspection by 01Date 0 Manteca 823-7104 Final Inspection by Date /f 0 Tracy 835-6385 Applicant - Return all copies to: Environn nt* Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �sy3 14i0 EH 13-24 REV. 10/82 10/82 500 14-26