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I APPLICATION FOR PERMIT I SAN JOAQUiN LOCAL HEALTH DISTRICT rk 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 /Jvq�� i Telephone (209) 466-6781 DATE ISSUED //30/0,3 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - —T' Y� described, (Complete in Triplicate) plication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein This application is .made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump d the Rules and Regulationns ofthe San Joaguin Local Health District, b Address ,'��a Y2f� �TG�P� 5�, Subdiviision Name "ner's Name /fT Address 1/�3 �1 ri�ic . f7��1 Phonntractor's Name y,� License No. Phone I �." TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W jj. Tr1[ PUMP INSTALLATION -SYSTEM.REPAIR ++►—DTHER❑j�-�� DISTANCE TO NEAREST: SEPTIC TAN M SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATIONAL AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPEOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` J— Industrial U Open Bottom ° Q Mantecat Dia.%sof Well Excavation ;! F-1 Domestic/Private ❑Gravel Pack ❑ Tracy / Dia. of Well Casing 1 i 1-7Public ❑ Other E]Delta /�/ Type o Casing'- 77, irrigationApprox. ❑ Eastern - Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout ❑Other Surface Seal Installed by r Repair Work Done F] Type of Pumpl H.P."` State Work Done Well Destruction ❑ Well Diameter $eating Material (top 50') Depth I Filler Material (Below 50') VV TYPE OF EPTIC WORK: NEW INSTALLATION Ki REPAIR%ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) J1 Installation will serve: Resid3ience _✓ Commercial Other ! J! Number of bedrooms Lot size �X�4O/,�, �,�_' Number of iiving units: Character of soil to a depth orf13 feet: Water table depth SEPTIC TANK 7Q Type/Mfg Capacity �'�1 No. Compartments i PKG. TREATMENT PLT. ❑ Type/Mfg 4 f Capacity f Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation. A Property Line / DESTRUCTION ❑ 1# rel 1 ! LEACHING LINE No. & Length of lines --w ' Total length/size 4 r 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SE PAGE PITS ❑ Depth Size Number / y SUMPS LX Distance to nearest: Well �''/ Foundation �}�0 Property Line _ J. DISPOSAL PONOS ❑I "` I hereby certify that I have prepared this application and that,the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall ,$mploy persons subject to workman's compensation laws of California." I The applica t must call for allrequ r d inspections. Complete drawing n reverse side. k Signed ( Title: Date: ~�� � !!! � ATM ENTUSE ONL&,:,f- i Application Accepted by : A ea Stk 466=5781 1 Additional Comments: ❑ Lodi 3 621 k Pit or Grout Inspection by Date LJ Manteca 823-7164 1 Final Inspection by Date f L7 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 DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 1 J 10/82 500 EH 13-24 REV. 10/82 } 14-26 _ e k