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t i APPLICATION FOR PERMIT" SAN JOAQUINELOCAL HEALTH DISTRICT 1601 E, HAZELTON,AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED { PERMIT EXPIRES 1YEAR FROM DATE ISSUED j (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.Heal h District. Job Address %Z6 8 So: 1"1'� -r vY Lw�- Sub 4r sion Name Owner's Name &76 Address-s �„t� " Phone $3$' /10 91 Contractor's Name �, �,�7l�d�Y�/ "__ License No. �1 Phone �3� TYPE OF WELL/PUMP WORK: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK +1 SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION it AGRICULTURE WELL OTHER WELL i. PITS/SUMPS ;INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS z 1:] Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation U D mestic/Pri.vate_F_• Gravel Pack ❑Tracy Dia. of Well Casing r+ ❑ Public ❑Other �r ❑ Delta —Type of Casing.,_ ❑ Irrigation Approx. ❑Eastern Specifications F-1 Cathodic Protection Depth Depth of Grout Seal Geophysical • a''`` A '" �� r TYPe of Grout 1-71 Other r Surface Seal Installed by , Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑. Well Diameter Sealing Material (top 501) - --Depth- 41 .t Filler,Material (Below 50') TYPE OF SEPTIC WORK: .NEW INSTALLATION L-�_KPAIR/ADDITION (No,septic.tank or-seepage pit permitted if public sewer is sg kis available within 200 feet.) Installation will ser'AN\Residence Commerciall Other M" = Number of living units; fes•_ Number of bedrooms fk 3 Lot size l A cy e l y Character of soil to a depth of�3'feet: 5,4AId E ods �w )Water table depth 701 ` -"- ^^SEPTIC TANK [jj Type/Mfg Z3'e CAs7" Capacity /2e! +No. Compartments A l PKG. TREATMENT PLT. [] Type/Mfg Capacity-=- ' 'Method of Disposal }*• SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation" Property Line DESTRUCTION LEACHING k14F No. & Length of lihes I— '3a ' Total, length/size FILTER BED Distance to nearest':, Well 59' Foundation ;Z d Z. Property Line v` SEEPAGE PITS ❑ Depth Size 4" X !AC Xr1 d' .Number I SUMPS Distance,to:nearestr:' Well /a&' Foundation• S/4` Property Line DISPOSAL'PONDS- 'ET w ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county + _ r - -- ordinances, state laws, and rulesand regulations of the San Joaquin Local Health District., Home owner or licehsed 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 ariy pei=son 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-performa6ce of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California:" `- w -The-appl•icant`mu t-call for all required inspections. Complete'dirawing ons reverse side; r Signed X Title: Date: FOR P ENT USE ONLY. Application Accepted by ,moi' Area ! E] Stk 466-6761 Additional Comments: Lodi 369-3621 Pit or Grout Inspection bye Date . ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to:: Environm 1 Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT "DUE AMOUNT RECEIVED BY DATE PERMIT NO: INFO EH 13-24 REV. 10/82 10/82 500 P 14-26