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{ M + APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E, HA7ELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED 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 5o.h'osTerfal 11�;-4—e_k Subdivision Name Owner's Name Ae--e Address 33J7i7 S y`;�S7'� Phone Contractor's Name !,fl, -,'-,17141 License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r' 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [—j Other ❑ Delta irrigation Type of Casing Li 9 Approx. Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical ❑ Type of Grout Other Surface Seal Installed by W Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITION J (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: LNumber of bedrooms Lot size Character of soil to a depth of 3 feet: S,q{r�i <i/�daf 11 water table depth aea4- r SEPTIC TANK Ej Type/Mfg /21iea fiyg)" Capacity /+Toa No. Compartments :'t. PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal n SEWAGE SYSTEMDistance to nearest: Well //%� ' Foundation �pi Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines 7 - szo ' Total length/size / d FILTER BED ❑ Distance to nearest: Well 1A,9' Foundation 4-e Property Line d' SEEPAGE PITS Depth /�� Size 3 '%� /f .j/�' Number .7- SUMPS SUMPS Distance to nearest: Well /60 ' Foundation �hd " Property Line in' DISPOSAL PONDS ❑ ''"",t,�bx 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 must call for all required inspections. Complete drawing on reverse side. Signed X C 1/ _.f. Title: Date: FO$/DEPARTMENT USE ONLY Application Accepted bye Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date '' ❑ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental He/;(Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 71NFO — Ly ASE MOUNT DUE AMOUNT REMiTT D F RECEIVED BY DATE PERMIT N0. -s9s EH 13-24 REV. 10/82 10/82 500 14-26 F