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Y JG 9 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE,, STOCKTON, CA PERMIT NO. 'e3- Telephone (209) 466-6781 ` DATE ISSUED �/.y/�� 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 / �7 F(,� ^]�A-L Subdivision Name VIs= -IS 7 Owner's Name �j &_% Address 2-5-17 $'7, L illi 1 og Phone5�S4K�7-D3�� Contractor's NamePgCACJ${4 �y5 License No. ca!g2' Phone /� XR_ 4P2 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U 0� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (n Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta irrigation Type of Casing L_I 9 Approx. ❑ Eastern Specifications Cathodic Protection Depth + 17 Geophysical Depth of Grout Seal 4 ❑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 SEIPT$C WORK: NEW INSTALLATION U REPAIR/,ADDITION �(No septic tank or seepage pit permitted if public sewer is available within 200 feet) Install t1on will serve: Residence — Commercial _ Other ZZ)&-6+C-0 [s AN ❑ Numbertof living units: / Number of bedrooms C2 Lot size 9tOaC 199 r _❑ Character of soil to a depth of3 feet: !SA7Vfi Water table depth SEPTIC TANK Type/Mfg 1599,e_AeW5)V Capacity /,2Q 0 No. Compartments Z. - PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well t'Foundation �Q Property Line 3�_ { DESTRUCTION k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundat`inn= .' Property Line - SEEPAGE PITS [ 1 Depth Size Number SUMPS 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 workmans compensation laws of California.” Contractor's hi ing 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 ubject to workman's compensation laws of California." The applican t ,call f all re re�CtiComplete dr n reverse side. Signed X Title: Date:. FO.RARTM T U5E ONLY Application Accepted by Area — (} ❑ Stk 466-6781 Additional Comments: C] Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by ` ,- Datee� Tracy 835-6385 Applicant - Return all copies to: Environm taI Health Permit/Services-,1601 E. Hazelton Ave., P,O, Box 2009,-Stk„ CA 95201 �--_- --- r - - BASE AMOUNT_DUE.-.- -- AMOUNT REMITTEO�,�` RECEIVED_6Y DATEPERMIT NO. O w EH 13-24 REV. 10/82 10/82 500 14-26