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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 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 Address I S o mMD 2 u(,A Subdivision Name Owner's Name YJAIJL*L ICcevy Address Phone Contractor's Name -7—7,ry gigca< License No. yc3%/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION E] J SYSTEM REPAIR OTHER_Q P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL--F-CD. _- _ -i PRI)P LINE �"'► FOUNDATION AGRICULTURE_ WELL'"" 'OT EH R WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA - CONSTRUCTION SPECIFICATIONS 17 Industrial Ej-Open Bottom D Manteca Dia. of Well Excavation LX7 ❑ Domestic/Private—'' �Ej Grayal-Pack J Tracy Dia. of Well Casing Public other ❑Delta Irrigation + �' Type of Casing U ation 9 Approx. ❑ Eastern Cathodic Depth Specifications �Geophysical Depth of Grout Seal Other Type of Grout17 n , Surface Seal Installed by Y�n� Repair Work Done ❑ Type of Pump H.P. State Work Donees 1 Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is �alame - i200 feet,) Installation will serve: Residence Commercial OtherNumber of living units: Number of bedrooms Lot size • -? e Character of soil to a depth of 3 feet: SA o /G A,*7 Water table depth SEPTIC TANK [ Type/Mfg —PQ IZ CGg5T Capacity rad No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines _ r 0 0� Total length/size a c FILTER BED ❑ Distance to nearest: Well U O' Foundation /d Property Line /O` u SEEPAGE PITS Cj Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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 workmanK 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 11 for all required ins ctions. Complete drawing on reverse side. Signed X (^11 Title: C)'"ev vL late: J V Z^ ad 3 PARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date �, Manteca 823-7104 Final Inspection by �j _ Date /O.-.`Gp 7 Tracy 835-6385 Applicant - Return all copies to: (ifSvironmental 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 ISIR EH 13-24 REV. 10/82 a 10/82 500 14-26 r