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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, i Telephone (209) 466-6781 DATE ISSUED i 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 th ' aquin Local Health District, Job Addresv 497 PC a" syit&P RD Subdivision Name Owner's NameAddress r ,,tA Phone 4A Z2!3d Contractor's Name _ �Q„� JcbGGL License No. Phone i 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 ( FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 i Industrial I ❑Open Bottom ❑ Manteca Dia. of Well Excavation l _ r LJ Domestic/Private i s ❑Gravel-Pack,= ❑Tracy i Dia. of Well Casing 4 ❑ Public f Other3 ❑_Delta = Type of Casing j Irrigation Approx. I❑ Eastern i Specifications ❑Cathodic Protection Depth's E _• Depth:of Grout Seal ❑Geophysical' I Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ 'iType of=Pump 3 K.P-.\ 1 State Work Done ? Well Destruction ❑ ,Well Diameter t; Sealing Material (top 50') _ Depth i1 Filler Material (Below 50') ! _ TYPE OF SEPTIC WORK:%NEW,INSTALLATION.❑` REPAIR/ADO.IT-ION'-+�gf (No septic tank or seepage-pit'permitted-if public sewer is I� available within 200 feet.) Installation will serve: Residence Commercial _ Other: J4-C 1 Fl Number of living units: ►� Number of bedrooms Lot size _ li Character of soil to a depih of'3' feet: Water table depth . l Yr` S .. f6 SEPTIC TANK Type/Mf g, ',L Capacity � ) No. Compartments PKG: TREATMENTPLT, T e/Mf" , �'� 0y yp g � � '' ` .� Capacity- Method of Disposal ` SEWAGE SYSTEM \ Distance to nearest: Wella Foundation "�r� ��Property Line /s/-7— ' DESTRUCTION Q ^p"4 LEACHING LINE ''z,t �Jf TNo- &'Lel gth'�f Lines f(7 /� Total length/size FILTER BED "Distance, to.nearest:..,Wel 1 F Foundation Property Line SEEPAGE PITS '' ❑ ' Depth-,- =� Size. -. Number r ti SUMPS ❑ Dis9ta6 a to nearest: WeilFound*,ian Property Line #a DISPOSAL PONDS, ❑ I hereby certify that I have prepared fthis application and that the work will be done in accordance with,San Joaquin county ¢: ordinances, state laws, and rules andrreg'ulations of the San Joaquin'Local Health•District: — ' 3` Nome owner or licensed agent's signature certifies the following: "It 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:sha,ll employ persons subject to workman's;compensation laws of California." The applicant must call f ,a t quire nspections. . Complete drawing on reverse side. j Signed X Title: 4�1 Jam ' -, Date: fN Application Accepted by USE ONLY i�i2 %' Area �� ❑ Stk } 466-6781 Additional Comments: 1 ❑ Lodi 369-3621 , Pit or Grout Inspection by ' Date ❑ Manteca 823-7104 Final Inspection by1Oate,. z Tracy. 835-6385 Applicant - Return all copies to: ' En$ironmenta H alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . w FEE BASE AMOUNT DUE - AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13124 REV. 10/82 . ki. ... .._._.,_ — .._�- w. _,._..._ 10/82500 14-26 -