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APPLICATION FOR PERMIT <br />SAN JOAQU_I.N LOCAL -HEALTH DISTRICT V —7J <br />1601 E. HAZELTQN AVE., STOCKTON, CA PERMIT N0. <br />{ Telephore (209) 465-6781 ; <br />DATE ISSUED 7 Q <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete, -in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br />described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br />and the Rules and Regulations of the San Joaquin Local Health District, ," <br />Job Address z/ 4. .i/ 4a __ Subdivision Name J Z �s w <br />Owner's Name µ4. y4ddress Phone <br />Contractor's Name License No. - a-7 G Phone 7/ <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br />PUMP INSTALLATION F-1SYSTEM,REPAIR ❑ OTHER U <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSRL FED. PROP. LINE <br />FOUNDATION' AGRICULTUREWELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYRE OF WELL PROBLEM AREA <br />IJ Industrial U Open Bottom ❑ Manteca <br />Domestic/Private El Gravel Pack Tracy <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation _ <br />/Dia, of Well Casing <br />L] Public Other, Delta! / Type of Casing <br />p= <br />Li Irrigation Approx. Eastern Specifications <br />❑Cathodic Protection Depth <br />roDepth of Grout Seal <br />Geophysical Type of Grout <br />Otherti, .•�, <br />Surface Seal Installed by <br />Repair Work Done ❑ Type of Pump k " H.P." State Work Done <br />Well Destruction U Well Diameter'I Sealing Material (top 50') — <br />Depth ' Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION - RE•PAI,R/-ADDITION J (No septic tank or seepage pit perm•i'tted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence' c� Commercial Other <br />Number of living units: �,_ Number of bedrooms_ Lot size <br />• Character of soil to a depth of 3 feet: <br />Yi Water table depth <br />SEPTIC TANK Type/Mfg{% — L Capacity �jpf�L% No. Compartments <br />PKG. TREATMENT PLT. Type/Mfgy: Capacity Method of Disposal <br />fd <br />SEWAGE SYSTEM Distance to nearest: 4 Well %S� Foundation ]A2Property Line <br />DESTRUCTION - f <br />LEACHING LINE l� No. & Length of lines ` Total length/slze & <br />'�/ �i �- Foundation b"F Property Line low <br />FILTER 8€D E Distance'to- nearest:�Well .;`� <br />Size Number <br />SEEPAGE PITS Deptli " - <br />J. <br />SUMPS l—� Distance to nearest: Well Foundation Property tine <br />I hereby certify that 1 have prepared this application and that the work will 'b <br />done in accordance with San Joaquin county <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br />permit is issued, 1 shall not employ any person in such manner as to become subject to workman compensation laws of California." <br />Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which <br />this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />The applicant must call f r all equired insp tions. Complete drawing on reverse side. / g <br />Signed X <br />Title: Date: 1 <br />R EPARTMENT USWMNLY �. Stk 466-6781 <br />Application Accepted by Area <br />Lodi 369-3621 <br />Additional Comments: <br />{] Manteca 823-7104 <br />Pit or Grout Inspection by Daae <br />Final Inspection•by , <br />Date /_ ��� L7 Tracy 835-6385 <br />Applicant - Return all copies to vironmental Health Permit/services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA <br />i <br />EH 13-24 REV. 10/82 <br />14-26 f' <br />95201 <br />10/82 500 <br />AM <br />