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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) r i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein g 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 San Joaquin Local Health District. Job Address dlal 5 jH/� [> Subdivision-Name Owner's Name Address Phone Contractor's Name 4, License No. ;' Phone'= -TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Di STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL- FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL p C PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial ❑Open Bottom Manteca 'Dia.-of Well Excavation L j Domestic/Private ❑Gravel Pack Tracy I Dia. of Well Ca3ing Public ❑Other - ❑ Delta „ Type of Casing q Irrigation Approx.. ; `.❑ Eastern ) ❑i Cathodic Protection r' Depth € Specifications )✓ Geophysical ''✓ }{f Depth of Grout Seal a ❑Other f' Fi.6 Type of Grout Surface Seal Installed by R Repair Work Done ❑ Type"of Pump H.P. State Work Done s Well Destruction ❑ Wel 11 diamdf&,{- _:L E�SeaI i'q_g.ktd ial .(top 50') _ s.f Depthlt )_f Filler MaterialH Below 501) f C - .-TYPE OF SEPTIC WORK:: NEW INSTALLATION` REPAIR/.ADDITION'U'-(flo'septic tank or see page'-pit`permi#tedxifrpubl-ic sewer-1.5 r— ' W _r available within 200 feet.) 'Installation will serve: Residence Commercial _ Other Number of living units: •, Number of bedrooms Lot size / Character of.soil to a depth of 3 feet: u d 13 254 ti Water table !depth ^- SEPTIC TANK ❑ Type/Mfg ' sg ''"•r7. .Zw, i" Capacity No, Compartments _ 3 PKG, TREATMENT PLT. ❑ Type%Mfg A Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well �'f''s rFoungation �" Property Line DESTRUCTION - LEACHING LINE No. & Length of linesTata1 length/size FILTER BED Distance to nearest: Well :' y"• -Foundation Property, Line SEEPAGE PITS ❑ Depth. Size y 3(ay/ Number SUMPS Distance to nearest: Well Foundation ��Property Line DISPOSAL PONDS ❑ �. I hereby certify that IAave prepared this application and*that lthe work will be done in accordance wiA 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 thO in the performance of the work for which this permit is-A ssued, I shall not employ any person in such manner as to become subject to workman 1s compensation laws of California." Contractor's.h wing'or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is•.rssued, I shall employ persons subject to workman's compensation laws of California.," } The applicant must c 1 for l r �d in tions. Complete drawing on reverse side. Signed X. �t. µ_ »-_...T £le _� t Date: F P ENT.USE ONLY.. - i . r Application Accepted by - Area i ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by I Date ❑ Manteca 823-7104 jFinal Inspection by Date 1/ ❑ Tracy 835-6385 Applicant - Return all copies to: Envi.ronm J 1 HealtVPermit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FE E BASE AMOUNT DUE AMOUNT REMITTED RECEIVED.BY DATE . PERMIT NO. NFO 111?7 EH 13-24 REV. IO/B2 10/82 500 -14-26 i