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r APPLICATION FOR PERMIT ��E SAN 3OAQUiN LOCAL HEALTH DISTRICT � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. —q7 Srs Telephone (209) 466-6781 HATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t' (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 dr'No. 1862 for well/pump and the Rules and Regulations of the San J9,aquin/JLocal Health District. rl Job Address_ 2 /� ��p S "?I'd _ Subdivision Name Owner's Name (, Address /�Gam, n� _Y�f�}G Phone_6_1,7.r]7tj'� Contractor's Name License No, Phone036-ZZ4?7- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑- PUMP INSTALLATION SYSTEM REPAIR BOTHER ❑ DISTANCE TO NEAREST:',SEPTIC TANK SEWER LINES OISPOSAL',FLD. PROF. LINE FOUNDATION AGRICULTURE WELL s OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I=J Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other [ Delta 1 Type of Casing �✓ Lj Irrigation Approx. [] Eastern Cathodic Protection Depth Specifications El � Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump _5�- /15W H.P. ` State Work' Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No' septic tank or seepage pit permitted if public sewer is available within 200 feet.) 'f Installation will serve: Residence _ Commercial Other , 1 Number of living units: Number of bedrooms l-ot size Character of soil to a depth of 3 feet:-- - —water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PYG. TREATMENT PLT. [! Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE jJ No. &.-Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS �j Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be done it accordance with San Joaquin county . ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. j Home owner or -l'i'censed 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 applican t call for ll required in ctions. Complete drawing a side, Date: OR Signed ( Title: _ OR D TMEN Application ccepted by Area ��__ E]'Stk 466-6761 Additional Comments: [ Lodi 369-3621 Pit or Grout Inspectio by Date ❑ eca 823-7104 1, Final Inspection by Tracy 835-6385 Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA -95201 fi rEE BASE AMOUNT DUE AMOUNT R£MI77E0 RECEIVED BY DATE PERMIT NO. 10/82 500 -, EH 13-24 REV. 10/82 14-26