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r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AYE, STOCKTON, CA PERMIT NO. X55 �9 5 Telephone (209) 466-6781 DATE ISSUED 3-Zb-FSS 1 ( 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 it 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 Address 13�2J /U Gflt�t _] i,,r�-fn kd St/416bdivision Name Owner's Name �� a✓ t _ Address . Q, /3o S q /Phone Contractor's Name o..R.,,nce v,�u� r..F�cense No. 3 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR- OTHER U DISTANCE TO'NIAREST,:j'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATICN. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE F TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial - - J U Open Bottom [� Manteca" - = Dia:- of-Well 'Excavation-- El Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing 17 Public [-1 Other ❑ Delta gIrrigation Type of Casing I 9 Approx. ❑ Eastern Depth Specifications Cathodic Protection p Depth of Grout seal � L7 Geophysical I Other Type of Grout N Surface Seal Installed by f Repair Work Done Type of Pump H. `j State Work Done Change- u-rh�Ho, To Ste. Z Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION [D (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) k Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size 1 Character of soil to a depth of 3 feet: Water table depth ! n SEPTIC TANK :Type/Mfg_ Capacity No- Compartments t/ PKG. TREATMENT PLT. ,E] Type/Mfg Capacity Method of Disposal {� SEWAGE SYSTEM ; Distance to nearest: Well Foundation Property Line , DESTRUCTION -;r;0 LEACHING LINE U No. & Length.of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line. r SEEPAGE PITS Depth Size Number +� SUMPS - .�' _L1 ..Distance.to nearest: -Well Foundation Property. Line_ 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' s6ch 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 s 'employ persons subject to workman's compensation laws of California," The applican us ca 1ori 1' requiKed inspections. Complete drawing on reverse side. GG Signed X Title: <1e, � Date: 3 OR DEPA MENTU E QJ * rU Application Accepted byd ' �� Area [] Stk 466-6781 Additional Comments: n �Lodi•• � # �l Pit or Grout Inspection by, Date n ca Final Inspection by Date -� � ' 7 835-6385 E&r n �+ Applicant - Return all copies to: . Emental Health Permit/Services 1601 E. Hazelton AV P. Box 2009, Stk., �CA�qy�9*52 ,1A r- `� � '!H FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE -PERM ITNO INFO $ i'Eia� yy EH 13-24 REV, 10/82 Y 10/82 500 , 14-26 f