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r APPLICATION FOR PERMIT SAN JOAQUIN' LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete it 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,00 the jani Joaquin Local Health District. Job Address �c l0 a6 CI",+,4 'Jt` � t SCWOS%tdi vision Name Owner's Name 1�� N IN7+55 Address Phone 38 3290 Contractor's Name TIM C'AR614e License No. 2�/3c1/If Phone ,?��j 2/ �6 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE -WELL— OTHERWELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 1 Industrial U Open Bottom - Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta ! Type of Casing Irrigation Approx. Eastern Specifications d E] Cathodic Protection Depth Cathodic Depth of-Grout-Seal - ❑Geophysical Type of Grout ❑Other Surface Seal Installed by i Repair Work Done D Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ ! Depth Filler Material (Below 50') i TYPE W SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _✓0 Commercial _ Other 7 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: O —Water table depth r SEPTIC TANK Cj Type/Mfg Capacity 604 No. Compartments .2 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 0 ` Total length size FILTER BED ❑ Distance to nearest: Well 41S0' Foundation /O Property Line $d� [l" SEEPAGE PITS Depth Size Number SUMPS 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 workman 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 per ons subject to workman's compensation laws of California." The applicant m 11 for ail quire inspections. Complete drawing on reverse side. _ - SS Signed X /vs"� /� Title: 0W1y trt Date: F ARTM T USE ONLY ❑ Application Accepted by .�- Area _'09- Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date l Manteca 823-7104 Final Inspection by Date S ❑ Tracy 835-6385 Applicant - Return all copies to: Environment.} Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 Eh 13-24 REV. 10/82 14-26