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is go rM APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 Qq � 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 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 Locai Healt District. Job Address 4P JVD)LL aP_ ubdi vision Name Owner's Name V146;&4e.4 j,fIA472--i-- Address ;Sgwyg Phone "&5L?g7r Contractor's Name Z=&Xz> E, ,Wer j--> License No. e&!,��-76 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP+INSTALLATIONSYSTEM IREPAIR"'""'" —OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 4 � 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL { PROBLEM AREA CONSTRUCTION SPECIFICATIONS W I Industrial U',Open'Bottom E] Manteca Dia,.of Well Excavation f LJ Domestic/Private Gravel Pack [] Tracy Dia. of Well,Casing V PublicOther. F Celt � �1 ❑ Type of Casing Lj Irrigation 4 Approx. ❑ Eas r El Cathodic Protection P Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout Other d # Surface SeallInstalled by Repair Work Done ❑ Type of PumprA H.P. State Work Done ( n Well Destruction F-1Well Diameter , f' Sealing Material (top 50') w)S Depth Filler Material (Below 50') r" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION * (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial '_ Other - J Number of living units: umber of bedrooms 2 Lot size Character of soil to al ?trYt�f3"fee Water table depth 10(SEPTIC TANK � Type/Mfg s Capacity No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg f Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ t I LEACHING LINE [La/, No. & Length of lines / �Y Total length/size - 7 FILTER BED Distance'to nearest: Well — Foundation � Property Line f j SEEPAGE PITS Eel Depth Size � Number 1 f SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL. PONDS X1091/C- IV`47250e 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 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 workmanli 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 for all required inspections. Complete drawing on reverse side. Signed X _ _ ( Title: ' ,� Date: I/— F CEP RTMENT USE ONLY Application Accepted by Area �� Stk 466-6 Additional Comments: Lodi 369-3622 Pit or Grout Inspection Cate Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all co ieso: Environm al H th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 14-26