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P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, --Cl Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED E (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 Sa Joaquin Local Health District. Job Address .. 1't L(f` 1/2�, - -571k, Subdivision Name r Owner's Name JD-c S,'#vtelneAddress _ b � 5 p:(� Phi"e Contractor's Name r License,No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-PUMP INSTALLATION SYSTEM REPAIR OTHER ) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public ['_j Other, Delta irrigation Type of Casing 9 Approx. ❑ Eastern [] Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal 17 Type of Grout F-1Other � Surface Seal Installed by tr Repair Work Done Type of Pump H.P. State Work Done -�^ Well Destruction Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ! ! available within 200 feet,) a Installation will serve: Residence _ Commercial Other Number of living units: Number of�be/d�rooms Lot size , Character of soil to a depth of 3'feet: q!Ck-V Water table depth SEPTIC TANK e Type/Mfg':1—JC1?r1-CA2.4C---- Capacity Z-C�D;W(, No, Compartments Z PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line. DESTRUCTION ❑ Il LEACHING LINE No. & Length of lines Total length/size /Q� FILTER BED Distance'to nearest: Well Foundation Property Line SEEPAGE PITS Depth Q Size ��X �'! Number i SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS t i 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 workmant 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," 4 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: — f EPARTMENT USE ONLY Application Accepted b I Area Stk 466-6781 Additional Comments: � p N')-- '11—g 3 Lodi 369-3621 Pit or Grout Inspection by C. ,, 4 Date Manteca 823-7104 Final Inspection by Date Thy- �Z'g� L Tracy $35-6385 Applicant - Return all copies to: .,#Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE A RECEIVED BY DATE PERMIT NO. INFO tJ /," & 5: - L= d- i EH 13-24 REV. 10/82 n / 10/82 500 14-26 }V�