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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 72— 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 Regula i ns of the San Joaquin Local Health District. Job Address �2 Subdivision Name Owner's Name a Address Phone Contractor's Name k,&9V 13 Q L(, License Na. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE U 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public [j Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Depth Specifications ❑ n Cathodic Protectio1 Depth of Grout Seal 0 ❑Geophysical Type of Grout Lf Other Surface Seal Installed by Repair Work Done ❑ _Type of Pump H.P. State Work Done 74:1 Well Destruction ❑ -Well Diameter Sealing Material (top 50') Depth Filler Material (Below SO') m TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ] (No septic tank or seepage pit permitted if public sewer is IIPF, available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms -2 Lot size 160 y /40, Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i� Capacity a0 a No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg, Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well r Foundation Property Line DESTRUCTION ti LEACHING LINE — No. & Length of lines i 4 d a Total length/size 00 FILTER BED ❑ Distance to nearest: Wel1OV&- ID61 Foundation Ww-/dl Property Line SEEPAGE PITS ❑ Depth Size dKk fr" Number L SUMPS Distance to nearest: Well ,a I Foundation _av14r /AO I Property Line � 1 DISPOSAL PONDS ❑ S ayvfr� l•�a a s a 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 t call all required inspections. Complete dna g on reverse side. Signed X Title: Date: F R DEP TMENT USE ONLY / Application cep ed by Area E] 5tk 466-6781 Additional Comments: L] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection byDate �/ ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental He Av Permit/Services 1601 E. Hazelton e., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ff7O EH 13-24 REV. 10/82 14-26 �� 10/82 500 (—�