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F �Z APPLICATION FOR PERMIT !, SAN LOCAL HEALTH DISTRICT it 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. T S- Telephone (209) 466-6781 DATE ISSUED 5:��$Li 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 ,�'fO-"—,V& • Subdivision Name Owner's Name fir/ G Address �' 3 Al Phone _IY3 2-X il ' Contractor's Name F/_0 yo A/Owh License No. yrz Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION Ej t PUMP INSTALLATION- ❑ SYSTEM REPAIR — OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ open Bottom ❑ Manteca Dia. of Well Excavation F-1 Domestic/Private ❑Gravel Pack L:]-Tracy. Did. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing F, irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by 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 ❑ REPAIR/ADDITION Le (No septic tank or seepage pit permitted if public sewer is QZ ` available within 200 feet.) Installation will serve: Residence A Commercial '_ Other r Number of living units: Number of bedrooms 2— Lot size S-S jl(fp"D Character of soil to a depth of 3-feet:. , LL,44y 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 ❑ No. & Length of lines Q Y i '�7 A/6- Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS EK ,Depth s2SI mak. Size 19L Number SUMPS ❑ Distance.-to nearest: Well -L Foundation Property Line _ DISPOSAL PONDS I hereby certify that I have prepared-this,a"l ication anzl that-Che-work-wil-1 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 persons subject to workman's compensation laws of California." The applicant must call fo all requir d inspections. Complete drawing on reverse side. _ Signed X� �� Title: Date: A Application Accepted by OEPARTMEN USE ONLY 5e� �, � 5tk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date s- E Manteca 823-7104 Final Inspection by Date --7- ❑ Tracy 835-6385 Applicant - Return all copies to: . Environmen Health Permit/Services 1601 E. Hazelton Arae„ P.Q. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a O EH 13-24 REV. 10/82 10/82 500 14-26 r