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t APPLICATION+FOR PERMIT , z SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209)'466-6781 GATE ISSUED ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ (Complete in Triplicate) Application is he_reby'made to the Sari 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 Local Health District. Job Address /��/ '/19T, l� =rL�/j</ . j,.A� Subdivision Name Owner's Name �dv//�i/f/ �n�.uerTy Address //,S'ol I!IV-, Phone Contractor's Name License No,- /yy— meq/ Phone ti TYPE OF WELL/PUMP WORK:.- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHERLJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONS —AGRICULTURE-WEL"L—— — OTHER WELD PITS/SUMPS INTENDED USE �. TYPE OFJWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout-Seal ❑ Geophysical Type of Grout LJ Other Surface Seal Installed by Q, Repair Work Done ❑' Type of Pump H.P. State Work Done 1' Well Destruction ❑ Well Diameter Sealing Material(top 50')_ Depth !' Filler Material (Below 50') TYPE OF SEPTIC WORK NEW INSTALLATIYON ❑ REPAIR/ADDITION (Z (No septic tank or seepage pit permitted if public sewer is _ _I available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units:. / _Number of bedrooms .3 Lot size V Ff�r e y s. Character of soil to a depth of 3 ,feet: 49.6 r AOV91JWater table depth SEPTIC TANK L!xj, Type/Mfg C_4 rdi— a y. 1 P047 No. Compartments 7� PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 6o ' Foundation -7c ' Property Line _�r'd DESTRUCTION ❑ =.1 LEACHING LINE U :No. I Length of lines 3` ro — 3 �, Total length/size 7 Yo FILTER BED ❑ Distance,to nearest: Well 9b Foundation rfe ' Property Line SEEPAGE PITS ❑ 'Depth - . - Size A Number SUMPS `❑ Distance.to nearest: Well Foundation Property line DISPOSAL-PONDS ❑ ;" _ I hereby certify thiat •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 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 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 c% O Title:' " " ' Date: FO PARTM T USE ONLY / J Application Accepted by Area ❑ S"tk 466-6781 Additional Comments: —�� ❑ Lodi 369-3621 Pit or Grout Inspection by Date L] Manteca 823-1104 Final Inspection by — _ =� _ Date ❑ Tracy 835-6385 Applicant - Return all copies to: En vironmenA Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE SASEOUNT DUE . AMOUNT REMITTED` RECEIVED BY DATE PERMIT N0. INFO cry i1 EH 13-24 REV. 10/82 10/82 500 14-26 11 r