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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. LA 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 41,24 Subdivision Name Owner's Name T p• Al E?y ESS/j� Address 'lam' Phone 464--8 Contractor's Name //g6�yr/ L!/G L :V&La/Aj! )License No. 3-7o8'Z Phone -75'1- 3 377 -� TYPE OF WELL/PUMP WORK: NEW WELL [j WELL REPLACEMENT ❑ DESTRUCTIONX PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER U DISTANCE TO NEAREST: SEPTIC TANK gQ _ SEWER LINES 9S DISPOSAL FLO. PROP. LINE /S FOUNDATION AGRICULTURE WELL OTHER WELL /eO tPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom Ej Manteca Dia. of Well Excavation t i /P ti Domescrvae ` J LJ � Gravel Pack � Tracy Dia. of Well Casing Public Other Delta Type of Casing S Ttds-CL_ V Irrigation Approx. Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout q1!5', (g,A sf VV 67.P"T ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane Well DestructionWell Diameter Sealing Material (top 50') Depth — 7 Filler Material (Below 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS l—� 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 such manner as to become subject to workmanIs 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 applican ust cal for al] re iqu•red inspections. Complete drawing on reverse side. Signed X fyd7l�U® '�'v Title: Date: 3'z� F D AR USE ONLY Application Accepted by Area _ Stk 466-6781 Additional Comments: Lodi 368-3621 Pit or Grout Inspection b Date Ll Manteca 823-7104 Final Inspection by * Date y'j�� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental 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 FH 13-24 REV. 10/82 10/82 500 14-26