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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTHDISTRICT .(7 3-- 163 r `• 0 " 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. r° a Telephone (209) 466-6781 ' DATE ISSUED C 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f r. (Complete in Triplicate) Application "ishereby made;,tothe San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicat'ibn 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 Lo al Health District... �a Job Address D (.f 'l4 fL �r 7a Subdivision Name �"C�e�`®t. r Owner's Name r,3' ¢- f Address ff -r- h Ph ne � Phone %L--74 Contractor's Nam ' j License No-.. Y Name,-q4, ' TYPE OF WELL/PUMP WORK: NEW WELL D WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION M SYSTEM REPAIR OTHER U } E. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNOATiON AGRICULTURE WELLY OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREAv CONSTRUCTION SPECIFICATIONS NJ EDia. of Well Excavation k F Industrial U Open Bottom ❑Manteca 1 Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta Type of Casing ` L iIrrigation Approx. E] Eastern Specifications Cathodic Protection Depth t Depth of Grout Seal Geophysical Type -of Grout 7, U Other Surface Seal Installed by Repair Work Done gJ Type,of Pump S � H. State Work Dane — a Well Destruction ❑ We11.,Diameter Sealing Material (top 50') W-- Depth Filler Material (Below 50') # i TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/,.ADDITION D (No septic tank or seepage pit; permitted ifpublic lable within 200fsete) is is♦ Installation will serve: Residence Commercial _ Other s r Number of living units: Number of bedroomsLot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capaci„ty, : No. Compartments + _ •+ , + Capacity Method of Disposal I PKG. TREATMENT PLT. Type/Mfg i SEWAGE SYSTEM r Distance to nearest: Well Foundation Property Line DESTRUCTION Length of lines Total length/size No. & LEACHING LINE ❑ g Distance to nearest: Well Foundation Property Line FILTER BED �-' SEEPAGE PITS Depth Size i (Number �� SUMPS Distance to nearest: Well FI un dation`A Property Line DISPOSAL PONDS I have prepared this,application and that the work will be done in accordance with San Joaquin county hereby certify that`I ordinances, state laws,;.and rules and regulations of the San`"OaaquinfLocal Health:.District.- k 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 workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation laws of California.” k The applicant must call for all r u' inseecti s. Complete drraaw]ing on reverse side. Signed X {' ' ,, Title: ~T►�b i Date: c3 F DEMENT USE LY Application ❑ Stk 466-6781 ! Application A ce ted b Lodi 369-3621 Additional Comments: Manteca 823-7104 Tracy 835-6385 Pit or Grout Inspecti b Date J��,�+5y Final Inspection`by Date �+ ❑ it/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 Applicant �- Return all copie nvironmental Health Perm FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE _ PERMIT NO. INFO 1 f . F z 10/82 500 I EH 13-24 REV, 10/82 14-26