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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 73-1()610 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. J `/ ((OO Telephone (209) 466-67B1 DATE ISSUED c�lO 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 d Regulations of the San ° oaquin Local Health District. Job Address yoo C rIe—c�'o N RQi%o Subdivision Name Owner's Name P4 4L. Address Phone L " ,v� CgQ4,e1 License No: ��/'S`y,$ Phone $23 �5� Contractor's Name . TYPE OF WELL/PUMP WORK: NEW WELL -WELL REPLACEMENT [:] DESTRUCTION �. PUMP INSTALLATION SYSTEM REPAIR 1-1 OTHER LJ tA� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -� O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private �Gravel Pack Tracy Dia. of Well Casing E] Public [Other El Delta Type of Casing u Irrigation Approx. Eastern Specifications Cathodic Protection Depth a Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done + Well Destruction U ' Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') o!� TYPE OF SEPTIC WORK: NEW INSTALLATION [_J REPAIR/ADDITION 11 (No septic tank or seepage pit permitted if public sewer is Q available within 200 feet.) Q�, Installation will serve: Residence X Commercial _ Other Number of living units: I Number of bedrooms 2 Lot size /�ICR '� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line � DESTRUCTION LEACHING LINE ) No. & Length of lines 1" 7Total length/size v f L r ! FILTER BED LV Distance to nearest: Well SD' Foundation j a Property Line 7�^' ©i X .21 SEEPAGE PITS Cj Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 I' 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 f' this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applica t ca11 for all wired inspections. Complete drawing on reverse side. -3 Signed o Title: Date: ff JJ O � X. {Oh'1 h .._.. _. OR DEPARTMENT USE ONLY0Stk 466-6781 Application Accepted by Area Lodi 369-3621 Additional Comments: 4 ! Date Manteca 823-7104 Pit or Grout Inspection by Final Inspection by Date l- ❑ Tracy 835-6385 Applicant - Return all copie to: .,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE . PERMIT N0. i INFO U Od q y � G J -�� 1O1l l I0/82 500 EH 13-24 REV, 10/82 14-26 bel