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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO-6 Telephone (209) 466-6781 DATE ISSUED t 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 workherein 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 h�of��:t//he San Joaquin Local He;31th District.; Job Address f`�� /Vr ,CGtarer_-S;je, Rel Subdivision Name Owner's Name A. Address s- Phone C1 Contractor's Name �igjx .P5'A�7 C y - _ License No. 4/ ` Phone �1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ® DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [� DISTANCE TO NEAREST: SEPTIC TANK] SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1) AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPO OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta. Type of Casing ❑ Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Other Surface Seal.Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50') + Depth t� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D< (No septic tank or seepage pit permitted if public sewer is .0 available within 200 feet.) Installation will serve: Residence _ Commercial Other 'Number of living units: 11 Number of bedrooms Lot size t� Character of soil to a depth o��3 feet: Water table depth �+ Ik SEPTIC TANK X Type/Mfg 'Pik nc 4,'y/.,v Capacity No. Compartments F PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines / `/C? Totaallt�length/size /0C, )c 2 FILTER BED ❑ Distance to nearest: Well Foundation �7y Property Line /00 SE€PAGE PITS Depth 2-5— _ Size _ Number i SUMPS U Distance to nearest: Well Foundation ? Property Line �L40 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 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 music ll for a ;requi ns tions. Complete draw' o, verse si i Signed Title: Date: PARTMENT USE ONLY 1.L Application Accepted by Area1/I"�� ❑ Stk 466-6781 Additional Comments: FEKodi 369-3621 ! Pit or Grout Inspection by Date ❑ Manteca 823-7104 € Final Inspection by Date Z-2-7,Z ❑ Tracy 835-6385 Applicant - Return all copies to: Environm ntal Health Permit/Services 16011. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT:MOUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 4 EH 13=24 REV. 10/82 10/82 500 14-26