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APPLICATIONFORPERMIT,, .t /to s i JOAQUIN LOCAL HEALTH DISTRICT ` - 1601 E. HAZELTON-AVE., STOCKTON, CA PERMIT NO. 8 ' - Telephone (209) 466-6181 $•� t 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 R uyla ions okthe Sa bJUoaquin Local Health District. ,//�� ,, 6 Job Address / V -~ $ub ivissiionnNName Y-Mh -4 Owner's Name N Address ' �� e/O/! Phone � \ Contractor's Name /9 t License No. _ 3 Phone — C TYPE OF WELL/PUMP WORK: ,NEW WELL ❑, - WELL REPLACEMENT ,❑ • RESTR66TION ❑ ` '. 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 WELL ••PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Do' Pi to ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑Public ❑Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑Eastern Specifications ❑Cathodic ProtectionDepth . Depth of Grout'Seat ' ❑Geophysical ' - Type of Grout. ❑Other. Surface Seal Installed by Repair Work Done ❑ Type of Pump H.Q. State Fork Done Well Destruction ❑ Well Diameter - Sealing Material (top 50') Depth, Filler Material (Below. 50') - _ �j• -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 _ Otherl Number of of soi units:' / Number feet: of bedrooms �3 Lot size Character of soil *to a depth of 3 feet: � �/ "� � Water table depth SEPTIC TANK - ,, Type/Mfg ' 4C45Wf, /J-/N/( Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg r ' ' _ — Capacity Method of Disposal Septic Tanl k Distance to nearest: NelFoundation Wroperty.Line 1 LEACHING LINE ❑ No. E. length .of lines. 2 Total/l)ength/size FILTER BED ❑ Distance to nearest: Well /Jb Foundavion 5W Property Line 10 , _ SEEPAGE PITS Depth Size ' Number SUMPS' L) Distance tp nearest: Well Foundat,t on ' Property Line DISPOSAL PONDS Q 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 slgnature 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 workmant compensation laws of California." Contractor's hiring or•sub-contractinU signature.certifies the following: 1'I certify that in the,performance of the work for which this permit is ssu A, I shall epiploy per ns-suWect to workman's compensation laws of California." The applican st c1 fo ad equir inspections. -Complete growing on reverse side. �- 2�-_ ,� Z Signed % / Title: Date: R ART IT USE ONLY Application Accepted by. Area .dI ❑ Stk 466-6781 Additional Comments: _ ` ' ❑ Lodi 369-3621 Pit or Grout Inspection by - > Date Manteca 823-7104 Final Inspection by xi✓• Date %wZ-28-5�'-� Tracy 835-6385 Applicant - Return all copies to: En�,Health Permit/Ser"vice s•.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE , AMOUNT REMITTED RECEIVED BY DATE- PERMIT NO.+. INFO EH 13-24 REV. 10/82 `l /! _ 10/82 500 14-26