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APPLICATION FOR PERfV!7 SAN JOAQL,i'+ LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an !Re ul tions of the San Joaquin Local Health District, Job Address 963§ E /k1Dg H4.AH0 Subdivision Name Owner's Name F(1 f1)JCI /�S'(?OC01V Address Phone 3" .a 76 Contractor's Name —]%orn CAR&IM License No. Wdy/E3 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACMENT,.- DESTRUCTION PUMP INSTALLATION a ---- SYSTEM REFER- --• OTHER-.LJ- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LIME i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �} Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack [] Tracy Dia. of Well Casing Public ❑ Other_„�,,r,, j:, Delta.i i _.T of Casing +. Lj Irrigation Approx. El Eastern Cathodic Protection Depth Specifications Depth of Grout Seal � Geophysical Type of Grout ❑Other Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [J Well Diameter' Sealing Material (top 50') _ Depth a Filler Material (Below 50') - CSL TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION K) (No septic tank or seepage pit permitted if public sewer is 4 r available within 200 feet.)- Installation will serve: Residence _& Commercial _ Other Number of living units: 3 Number of be rooms Lot sizePso Y fL)0 i y V" Character of soil to a depth*,of j3 feet: Water table depth SEPTIC TANK E] Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. Type/Mfg r _ Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation - _ Property Line DESTRUCTION ❑ / LEACHING LINE ' J No. & Length of lines Total length/size /da FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth s Number SUMPS Distance to nearest: Well Founda Property Line DISPOSAL PONDS CI 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-1�erformancE'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 fallowing: "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 applican t call for a_1.1,require inspections. Complete drawing on-reverse side. u Signed X 1f a, Title: OVV/dE1—� Date: ✓ FOR D�R�jMEAT USE ONLY Application Accepted by f� + ' JIV,F/l�iQ•'Y�� Area 06 Stk 466-.6781 Additional Comments: i r 369-3621 Pit or Grout Inspectio by,, Date- _ FkSca 823-7104 Final Inspection by Date �� `r Tracy 835-6385 Applicant - Return all copies to; Envlrq ental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2009, St k., CA 95201 m FEE BASE AMOUNT DUE AMOUNT'REMITTED RECEIVED BY DATE PERMIT NO. .. .... ^I INFO -......., &2 Y7 9 b EH 13-24 REV. 10/82 10/82 500 14-26