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� ; 3 APPLICATION FOR PERMIT = ' } SAN-JCAQU�N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 11 r Telephone (209) 466-6781- DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described. This application is made it compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of thelSan Joaquin Local Health District, Job Address ' � [� S /V1Ge�ivl � Subdivision Name Owner's Name n ��.Cl�rr(Q,y' Address1?Q, �IC7 Phone -' w Contractor's Name „cwGL L?�Qj License No. Phone TYPE OF WELL;/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION t PUMP INSTALLATION SYSTEM REPAIR OTHER L DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD. PROP. LINE rr ¢ FOUNDATION F1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OPIWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j J Industria) (�Open Bottom Manteca Dia. of Well Excavation r a Domestic/LJ � Gravel Pack � Tracy, Dia. of Well Casing 17 Public X Other` Delta Type of Cas in Lilrrigation i Approx. Eastern"' Specifications Cathodic;-Protection Depth N Depth of Grout Seal L7 Geophysical y Type of Grout U_ Other ' t ( r Surface,tSeal Installed by r Repair Work Done ❑ Type'of Pump r H.P. State Work Done :_ f 3 y Well Destruction F-1iWell Diameter A Sealing Material (top 50') "x c'^r66pth:#t: s Filler Material (Below 50') TYPE OF SEPTIC'WCRK: PFw INSTALLATION Ll REPAIR/ADD'ITION .0 ,(No septic tank or seepage pit permitted if public sewer is 4 » -t.I I available within 200 feet.} Installation wil11 l serve: Residence Commercial Othei•� j' Cl I Y — Number of-living units: « Number of bedrooms f Lot size Character!of.soil.to.,a;d th of 3 feet: , i t.Water, table depth ) ,Type/Mfg t'`' Capacity _ Ti !No. Compartments SEPTIC TANK i PKG. TREATMENT PLT.' Type/kg Al f is Capacity iMethod of Disposal SEWAGE SYSTEM Di stanceac,"hearest: Well Foundation n� -r-•Property Line DESTRUCTION LEACHING LINE ) l Nof&'Lengfhlo.f•�'ines � �d F Total length/size ..._ la FILTER BED ❑ - Distance to nearest.: W6.1 Foundation Property Line 6 SEEPAGE PITS L Depth " 'Size Number SUMPS Distance to nearest: Ve1'J ; Foundation Property Line " DISPOSAL PODS t � I hereby certify that I have prepared this-application and that the work will be done in accordance with San Joaquin county ordinances,' sfii to laws, and rules and regula'ti,ons ofythe San Joaquin Local Health District. Homeowner or l-icensad agent's signatu'e ce�'t3,fies' 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-nanrer as to become subject to workman compensation laws of California." 1 Centras or's hiring or sub-contracting signature certifies the following:_"I.certify that in the performance of the work for which =} !'fhis.pe 'mi't is issued, I shall employ persons subject to workman's,compensation laws of California." I Thi applicant must ca all fired inspections. Complete drawing on reverse side. SignedIX; �� f Title: Date: FOR DEPARTMENT USE ONLY Appl:ir cati,on Accepted by Area /3 _ Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by .1 , Date Manteca 823-7104 { Final Inspection by Date Tracy 835-6385 . Applicant Return all copies to: Environmental Health Permi /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ' BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 7 DATE PFRMIT NO. , INFO, EH 13-24 REV. 10/82 / 1� L _ 10/82 500 t r