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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. (� Telephone (209) 466-6781 Q)m.l DATE ISSUED 7 �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application'is hereby made to the San JoaquinLocal 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 ocal Health District. Job Address 2-50 o Qe e clk e n Subdivision Name Owner's Name -.Address Q Phone Contractor's Name t yg�gs� No. q a(9 Phone /0 �_ f TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation S & Domestic/Private Gravel Pack Tracy Dia. of Well Casing I—] Public Other Delta Type of Casing Lj Irrigation Approx. [] Eastern Specifications ❑Cathodic Protection Depth Geophysical Depth of Grout Seal Type of Grout f U Other I C Q tl� Su6J Surface'Seal Installed by Repair Work Done Type of Pump J�^`"t -�—H.P Ya- State Work Done Well Destruction U Well Diameter Sealing Materia j top'50'}i a Depth_.v..._...,_ �� , Faller Material (Below 50') . TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other f' ` Number of living units: Number of bedrooms Lot si�yy1ze W Character of soil 'to a depth of 3 feet: t; Water table depth O SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ��•-� Distance to nearest: Well Foundation Property Line DESTRUCTION �--1 LEACHING LINE U No, & Length of lines ; Total length/size FILTER BED Distance to nearest: Well Foundation; Property Line r SEEPAGE PITS Cj Depth Size ; R Number SUMPS U Distance to nearest: Well Foundation' Property Line DISPOSAL PONDS a > l I hereby certify that I have prepared this application and that the workiwill 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 workmanS 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 appli must call or li r re nspections. Complete drawing on reverse side. Signed X Title: Date: 1 �&4 11AITMEN�USE ONLY Replication Accepted by � ,�,�>� Area d� ;?i,-5tk 466-6781 i Additional Comments: [_J Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by _ , _ L Date J/2` Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 rF LL BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT�NO. NFO �7 � 3 `��J--lP C i EH 13-24 REV. 10/82 /J �}/- ' l [ 10/82 500 14-26 Ck_t'-t"' [a 6