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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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. Jab Address 67 4,'J L. C „ 1�;nepi Subdivision Name Owner's Name o!n , _ E _Address 1+Z1,04D 4- S44-on, AE!�, '!F- C,e V phone 4C7Z-Pjg Contractor's Name f License No. Zit T Phone 166427941LQ 7_ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER n 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T' 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6� 17 Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private EJ Gravel Pack ❑ Tracy Dia. of Well Casing Public F-1 Other ❑ Delta Type of Casing LjIrrigation Approx. E]Eastern Specifications []Cathodic Protection Depth Depth of Grout Seal (�Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') __ R 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 a available within 200 feet.) Installation will serve: Residence X Commercial _ Other CA Number of living units: -41 Number of bedrooms Lot size _ S t Character of soil to a depth of 3 feet: . _ Water table depth Iye SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKE TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines / ;Total length/size ;;t 'c.c_V,0,E7 AJ{� FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number l SUMPS ❑ Distance to nearest: Well [>�� - Foundation -sO, Property Line E' DISPOSAL PONDS 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 h 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 per ns subject to workman's compensation laws of California." The applica m s call for 1 requiravinsvections. Compl to d on reverse side. t��p � Signed Title: Dater C40 FOR D RTMENT USE ONLY Application Accepted by Area ff _ Stk 466•-6781 Additional Comments: ❑ Lodi 369-3621 �pito�r ,Grro t In pection by Date Manteca 823-7104 Fine�rr �rspec i n by — Date //-�(pT�_� Tracy 835-6385 Applicant - Return all copies to: FI vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO C� Zr 0� EH 13-24 REV. 10/82 10/82 500 14-26