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APPLICATION FOR PERMIT SAN JOAQLi!N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone 12191 466-6781' DATE ISSUED 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 madeain compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquirl.Local Health District. Job Address 41]� �I�L t i 41 Subdivision Name Owner's Name ,fit_ S�tz1 E 1 Address a. . Phone �u Contractor's Name �pR,2;�j_ I : License Na. Phone-(jam[„— Z_— �9 �5 TYPE OF WELL/PUMP WORK: NEW WALL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTAIL'LATION SYSTEM REPAIR ❑ BOTHER U DI-STA CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS—A LIFLD. <-PROP. CINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia, of Well Excavation LJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Publics [ Other Delta Type of Casing V Irrigation,, Approx. I] Eastern Specifications Cathodic�Protection Depth Depth of Grout Seal ,I Geophysical Type of Grout Other FF X i Surface Seal Installed by Repair Work Done El Type of�Pump H.P. State Work Done Well Destruction ❑ Well Diameter-./ %`/-7Sealing`_Material (top 50') K Depth Filler Material, (Below 50'), I TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITIS:y- (Nofs-eptic tank or seepage pit permitted if public sewer is C, , ; .+� , available within 200 feet.) i t'llorZU+o Installation will serve: Residence i Commercial _ Other- Number of living units: Number of bedrooms Lot size Character of soil to a depth of.3 feet: Water table depth {' No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity T �- �_" 'T -Capacity _. _ - --Metliod of-Di sposaT'""'— PKC. TREATMENT PLT. Type/Mfg f SEWAGE SYSTEM Distance to nearest: Well Foundation ..f e r Property Line � [m DESTRUCTION X i LEACHING LINE J No.' & Length of lines Totallength/size FILTER BED DistancOlto nearest: Well t,,r Foundation "' Property Line SEEPAGE PITS Depth I Size ' Numberl - '� SUMPS Di5tance'to nearest: Well Foundation P y 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 thiat i.r�tihe perfo"rmarscerof-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 fallowing: "1 certify that in the performance of the work for which bject to workman's compensation laws of California." this permit is slued, I shall employ persons s The appli an all f all re r d 'ns tion Comple e drawing on reverse side. Date9� nI Signed X Ti:tle3 � : t� Area D T US �Y - 5tk "'466-6783'- ' = ri ,__` _ Application Accepte y Additional- Comment •:ra , °0 Lodi k_369-3621 Pit or Grout inspection byj Date L Manteca 823-7104 Final Inspection by Dates -/��- Tracy 835-6385 't Se rust es 1 601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 . _ to:+ Environmental Health Perms / Applicant Return all - s FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO cc?? �uv 73—)OLP 10/82 500 EH 13-24 REV. 10/82 14-26