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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). OQ ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein L1J described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump 1 and the Rules and Regulations of the San Joaquin Local Health District. Job Address N_ Q .,—m rc iA to L., Subdivision Name : 00 04ACIA- � Owner's Name 1 o e,A.+„ T. facd Address � 3(? T'1zam tp-./ Phone Contractor's Name „S� 14, 'FAA Sy r3 License No, _`�i:3 C_ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U 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 � Specifications ❑ Cathodic Protection Depth Geophysical Depth of Grout Seal Other Type of Grout f_1 Surface Seal Installed by d' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50'} F TYPE OF SEPTIC WORK;. NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is J_ ,w available within 200 feet.) Installation will serve: Residence Z Commercial Other 3 Number of living units: _� Number of bedrooms . Lot size _ Character of soil to a depth of 3 feet: C Q Water table depth y 6� SEPTIC TANK CI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line ' DESTRUCTION ❑ LEACHING LINE f No. & Length of lines l�� 8s� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth • Size ,3ig;# Number 1 SUMPS U Distance to nearest: Well Foundation Property. Line Ar DISPOSAL PONDS ';PA'S1 / j0f7XI ..r 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 workman5 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 nt mu call r all required inspections. Complete dra ing on reverse side. Signed X Title: Date: EP MENT USE ONLY // pplication Accepted by Area // ® Stk 56-6781 Additional Comments: Or o7e.,:ah bvp4n a k1elic Q Lodi 369-3621 . Pit or Grout Inspection by d Date (,e Manteca 823-7104 Final Inspection by DateG 7�� Lj Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO fr y Lt s. o s33-H►i EH 13-24 REV. 10/82 10/82 500 14-26