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i + k 1 1 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL_HE.ALTH.DISTRICT 1601 E. HAZELTCN AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 s I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED } (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct are./or install the work herein and the Rules and Re described, This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ulations.of the San Joaauin Local Health District. . Job Address �� S �,'L a' Subdivision Name ` Owner's Name Address Z4 f j-8 J. hone 139—ifs Contractor's Named License No. Phone - TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION [J_ VIA : PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER L] W DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( 1 ' INTENDED USE TYPE OF W LL PROB M AREA CONSTRUCTION SPECIFIFj ATIO 1�/] industrial ❑ OpenfBo om nteca Dia. of Well ca d ' C LI Domestic/Private Grav3i ack racy Dia. of Well C ng Public Irrigation ❑ Oth el A X. Et rn Type of Casing F—IPP Cathodic Protection Depth Specifications Geophysical Depth of Grou Seal U Other Type of Grout 11 • Surface Seal Installed by Repair Work Done [J— Type of Pump H.P. State Work Done Well Destruction U Well Diameteri::_— Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is ¢ / Installation will serve: Residenlce f/ Commercial Other available within 200 feet.) Number of living units: ' 'Number of bedrooms 3 Lot size .3 dw, , Character of soil to a depth of 3 feet: 7 6 p Water table depth _ SEPTIC TANK X Type/Mfg Capacity �Z�O No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Ay Capacity TT Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well /l1�6 6 Foundation; /0 7— Property Line d DESTRUCTION ❑ I LEACHING LINE } No. & Length of lines Total len�th/size 2 0 3 Z FILTER BED Distance to nearest: Well loo Foundation EL tr Property Line SEEPAGE PITS ❑ Depth I Si a Number SUMPS Ll Distance to nearesJ� Foundation Property Line J DISPOSAL PONDS /'' 4 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 Lodal 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 following: "I certify that in the performance of the wk for which this permit is issued, I shell employ persons subject to workman's compensation laws of California." The applic must ca 1 or 11 required inspections- Complete drawing n reverse side. Signed X Title: � � ' Date: FOR AR NT USE ONLY Applicati Accepted by Area �3 5tk 466-fi781 Additional Comments: 719 / ❑ Lodi 369-3621 / Pit or Grout Inspection by Date Manteca 823-7104 ✓ Final Inspection by 1 Date L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO I I PERMIT N0. y EH 13-24 REV. 10/82 f 10/82 500 14-26 I Ul.