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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. v 3r- �1 7`T r Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (}3 r (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 and Regulations of the Sa//�911} Joaquin Local Health District. Job Address ZZI 7 ,_,Z'. 641VC�-2�V. � Subdivision Name Owner's Name J�� h ��YltiIB�S t Address Phone 4&2•-Z_.�� Contractor's NameFA=jsfj _1! pt4S License No. Phone 0 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LR D Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing L7 Public Other - kE] Delta Type of Casing D Irrigation Approx. D-,Eastern j Specifications D Cathodic Protection Depth i-. _ } Depth of Grout Seal 3 D Geophysical, Type of Grout ❑Other Surface Seal Installed by Repair Work,Done D Type of Pump; H.P. State Work Done Well Destruction s Well�.0iameter Sealing Material (top 50') + _ _.0 I 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.) Installation will serve: Residence >f Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of.3 feet: �S' Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method,of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property line DESTRUCTION " --• - LEACHING LINE [ No. & Length of lines - - - —Total .length/size-.:`-- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ej Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 ]oaquin Local Health District. Home owner or licensed agent's signature certifies the fdllowing: '"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 h' 'ng or sub-contracting signature certifies the following: "I certify-that-i'n-the-performance of the work for which this permit is _sued, I shall employ per_ s subject to workman's compensation laws of California." The applic 11 for requ'r nspect ns. Complet `dr on reverse side. Signed X Title: Date: R DEPARTMENT USE ONLY Application Accepted by Area —0-3— err 466-5781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date la Al Z L T.xa 835-6385 =Applicant-- Return'al-1-copie `Envircnmertal-Hea-lth Per0t/-Services--1601-E.--Ha2eltor-Ave., -P...0..Bok.- 09-, Stk,_-CA95201 FEE""" "'BASE— '""AMOUNT—DUE"'"'""`"'" AMOUNT"REMITTED'= �' -RECEIVED BY— -DATE INFQ EH 13-24 REV. 10/82 10/82 500 14-26