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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3d Telephone (209) 466-6781 5-3 S DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) C3L 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein w 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 Local Health District. Job Address 1P06/ /11QN7Sr2.VjW4 S,)- irks Subdivision Name Owner's Name /�i¢,t/c1pf. 1.4�ILr4 Address Lt F! iE Phone Contractor's Name &&g!e15/J _-<9ALS License No. c2 4!j1!FC&k3 Phone 4A(76-96,Q?_ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iJ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public OthDelta 17 Public � Type of Casing F, irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by O Repair Work Done ❑ Type of Pump H.P. State Work Done 3 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below -50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L'j( (No septic tank or seepage pit permitted if public sewer is C "'^r available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: __..L.— Number of bedrooms Lot size_49y k /3 �r7 f Character of soil to a depth of 3 feet: 6, Water table depth , ` 49 SEPTIC TANK Type/Mfg Capacity No. Compartments -t PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ s LEACHING LINE ig No. 9 Length of Tines �t7 Total length/size FILTER BED Distance to nearest: Well Foundation /O Property Line D-,O SEEPAGE PITS Depth Size s� Number J SUMPS U Distance to nearest: Well Foundation 1 d f Property Line 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 that in the performance of the work for which this permit is issued, I shall not employ any rs n in such manner as to became subject to workman compensation laws of California." Contractor's h' or sub-contracting gn ure certifies the following: "I certify that in the performance of the work for which this permit "s s ed, I shal employ ns subject to work an's compensation laws of California." The applic call fo 1 re d i'p ctions. Compl on reverse side. Signed Title: Date: - - FOR D RTMENT Application Accepted by Area Stk 4b6-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L] Manteca 823-7104 Final Inspection by Date /� 3 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT OUE AMOUNT REMITTED RECEIVED By DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26