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APPLICATION FOR PERMIT 14 SAN JOAQUi"I LOCAL HEALTH OISTR�. JUL �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 7 4 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUESAJOS',QU LOCAL (Complete in Triplicate) HV—A'LTH D;STRICT Applicatior 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 'F and the RuIeS and Regulations of .the San Jo quin Local Health District. Job Address 6 2-- /I• Subdivision Name !_ Owner's Name L!,-tddress y 6 1 -1- r, 'A-6. Phone q��—Y)Y Contractor's Name License No. f 1p 2 3 7 - Phone �J W TYPE OF-WELL/PUMP WORK: NEJ WELL ❑� WELL. REPLACEMENT DESTRUCTION (� PUMP INST4LLRTION I SYSTEM REPAIR OTHER 71 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE_ M K-._TYPE�OF WELL-: ,PROBLEM_AREA =: -._ C6N5T.RUCTION SPECIFICATIONS (_n Industrial U OpenIBottom 71Manteca Dia, of Well Excavation ii Domestic/Private Gravel Pack L Tracy Dia. of Well Casing I] Public Other Delta Type of Casing Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal 1-1 Geophysical / v// Type of Grout LJ Other Surface Seal Installed by Repair Work Done 2' Type of Pump H.P. State Work Done Well DestrIetion ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION �J REPAIR/ADDITION (_J (No septic tank or seepage pit permitted if public sewer is v _._. ,.,,_..,..,--- _, . available within- 200 feet.) ! Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a pt o depth f 3 feet: Water table depth SEPT T e `, Cap acity No. Compartments IC TANK Type/Mfg/Mf 9 PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal 4 SEWAGE SYSTEM 1-� Distance to nearest Well Foundation Property Line ` DESTRUCTION k LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property-Line DISPOSAL PONDS 5 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 Rand 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 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 st 11 for a squired ins ections`�. Complete win on reverse side. / Signed ( 'IT Oate:�r FOR DEPARTMENT USL ON Application Accepted by Area b - Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspectio y Date Manteca 823-7104 Final Inspection by 4' ilk. Date A AN ❑ Tracy 835-6385 Applicant - Return all copies toi Environmental Health Permit/Services 1601 E% Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE BASE AMOUNT DUE AMOUNT REMITTED _, .RECEIVED BY DATE PERMIT NO. INFO y� -71.�73 {93--`7781 EH 13-24 REV. 10/82 10/82 500 14-26 i