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r i I APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. ( Te1ephone_(209)!466-6781 . k DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the,'•5an 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 �Add resp '��S/-- .. ((wed„�- �'�e� Subdivision Name Owner's 9a JCC' Add r s� /A� t ne � !� �• { Contractor' , SAL-icense No. a��.�:�� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER•LINfS r .DISPOSAL FLD. PROP. LINE FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial ' J ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private Y U ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ public ❑Other ❑ Delta . .r. Type of Casing Irrigation Approx. ❑ Eastern ❑ Depth Specifications Cathodic Protection r Depth of Grout Seal ❑ Geophysical F [7j Other 1f Type of Grout Surface Seal Installed-by i 5 Repair Work Done ❑ Type of Pump � H.P. State-Work-Done U`l .Well Destruction — Well Diameter)` Sealing Material(to p 50') � Depth ! Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U” REPAIR/ADDITION ❑ (No septic tank or seepage pit .permitted if public sewer is f K / available within 200 feet.) Installation will serve: Residence Commercial > Other ;�''i` Number of living units: 1Number,of bedrooms Lot size w p , Character of soil to a depth of 3 feet:,. P' Water table depth"" C - SEPTIC TANK Ci Type/Mfgl} Capacity No. Compartments.A-" N PKG. TREATMENT PLT. ❑ Type/Mfg Capacity ''Metho-d-of-Disposal SEWAGE SYSTEMC] Distance+to nearest: Well Foundation— Property Line , DESTRUCTION r LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance�.rto nearest: 4fell Foundation Property Line SEEPAGE PITS ❑ Depth .L ksize Number _ SUMPS ❑ Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS t t • 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 applica must call for all required inspections. Complete drawing on reverse side.r CA Signed X �' ."'13Title: - ` - Dater fff DEPARTMEN E Oe �/� ❑ 466fi781 Application Accepted b .�3� ifY� Stk Additional Comments: ❑ Lodi 369-3522 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by ' ,[/{, ` Date L Tracy 835-6385 j Applicant - Return all copies to: Environmental Health: Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO v i -77.7 LH 13-24 REV. 10/82 a Q�T�. 10/82 500 14-26 !