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N ! - APPLICATION FOR PERMIT f SAN JOAQUiN LOCAL HEALTH DISTRICT 1 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. ' Telephcne (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F Application is hereby+made to the San Joaquin Local Health District for a permit to construct and/or install the work herein t described. This application is made in compliance with San Joaquin County Ordinarce No. 549 for sewage.vr No. 1862 for well/pump and the Rules and Regulations ofithe San Joaquin Loca Health District.. , j Job Address -'7C"yg � 1�ef��r.e�r�d�rxaa- _� Subdivision Name I Owner's Name (57r-044- IJ�S. S✓i; �e��a�+r�e �_ �Ol�d'ress / Phone Contractor's Name t&// License No. 1 —7Y3� Phone { TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �' 1111 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNOATION AGRICULTURE,WELL . OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF WELL PROBLEM AREA _CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑Manteca " Dia, of Well Excavation I Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [_1Other ❑ Delta Type of Casing F, Irrigation Approx. ❑ Eastern Specifications ❑ Chodic Protection r Depth atroecDepth of Grout Seal r � ❑ Geophysical Type of Grout V l Other Surface Seal Installed by d Repair Work Done [J -Type of Pump P. ✓/ State Work Done _,a Well Destruction ❑ ,Well Diameter Sealing Material (top 50') ` Depth Filler Material (Below 50') TYPE.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is r Availadle within. 200 feet:.)---.,;,.4 Installation will serve: Residence Commercial OtherF 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 4[ PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ i LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED [] Distance to nearest: Well Foundation Property Line F SEEPAGE PITS ❑j 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 f 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 workmanh 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." If The applicant must call for all'req 'red pections. Complete drawing on reverse side. 4/9,�� r Signed X Title: r� Date: li EP T NT U NLY f Application Ac epted y Area 0 ❑ Stk 4fi6-6781 k Additional Comments Lodi 369-3621 Pit or Grout Inspection b ^ Date Ll Manteca 823-7104 Final Inspection by Date —s L7 Tracy 835-6385 Applicant - Return all copi s to: Env'ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 =FELBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. y EH 13-24 REV. 10/82 10/82 500 14-26