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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 3 y`//'� s' ko.5 Te:;,- iid• Subdivision Name Owner's Name /.3ag e M' R,)ys- Address 3yjW 5, 0 5 rer 84. ]-}-/Y- Phone Contractor's Name /—'%A,;r,6y&/`r 5oly License No. *V 5EV - Phone ,�tt W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION 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 Industrial U Open Bottom Manteca Dia. of Well Excavation LJ Domestic/Private ❑ Gravel Pack Tracy Dia, of Well Casing, Public F-1 Other Delta Type of Casing LjIrrigation Approx. r-0 Eastern Specifications ._._� eCathodic Protection Depth; ct _ Depth of Grout seal [�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') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other TYsve G jy�yi Lnr Number of living units: / Number of bedrooms / Lot size -4'Tl 'Y�S Character of soil to a depth of 3 feet: C L..n Acy ..'4 Water table depth 5 SEPTIC TANK Type/Mfg CV7,yc, Capacity /a0 O No. Compartments --4 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM size th len Distance to nearest: Well .'Lfl 0 Foundation .Z o` Property tine inv -7P DESTRUCTION r ' 'LEACHING LINE '--u.—"No:'&'Length of'lines ' Total g / FILTER BED Distance to nearest: Well yyr`t0..` Foundation 30' Property Line ie e SEEPAGE PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONOS C1 I hereby certify that I have prepared this application and that the work will be done`fn`accordance wi'tYi San Jo�gOirrco-unty 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: Date: 4 FO IFPARTMENT USE ONLY — /�7 �j ¢� ❑ Application— ceptedTby, ,� /(f AtArea �_- /%r+ Stk 466-6781 Additional Comments: EJ Lodi 369-3621 Pit or Grout Inspection by Date 71 Manteca B23-7104 Final Inspection by Date / � L Tracy 835-6385 Applicant - Return all copies to: Environ al Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE r BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFa 10/82 500 EH 13-24 REV. 10/82 i 14-26