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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (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 tbe,.San Joaquin cal Health District. Type of Casing 5--fe Job Address LU es T d Specifications K Subdivision NameL/ e � Owner's Name !E'er=' l y Address .� G /P79SY9 Phone �3 �—�(�D 7 Contractor's Name � �2 �, 606,p� License No. Q(a Z Phone 3 '-f-0794 TYPE OF WELL/PUMP WORK: NEW WELL DISTANCE TO NEAREST PUMP INSTALLATION SEPTIC TANK FOUNDATION WELL REPLACEMENT ❑ DESTRUCTION) ❑ SYSTEM REPAIR OTHER L _ SEWER LINES DISPOSAL FLD AGRICULTURE WELL OTHER WELL PROP. LINE 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 5--fe irrigation_ Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal [] Geophysical Type of Grout Other S f e 1:..1 In t 11 ed b Repair Work Done ❑ Well Destruction ur ac s a y Type of Pump H.P. State Work Done Well Diameter Sealing Material (top 50') wf7rt eP SCC L Depth b Filler Material (Below 50') IZ, F C � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION i J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEMDistance to nearest: Well DESTRUCTION ❑ Other Lot size Water table depth _ Capacity No. Compartments _ Capacity Method of Disposal Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑j Depth Size Number SUMPS a 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 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 1s 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 applica nust call for ?required inspections. Complete drawing on revers ide. Signed X Title: Date: 12^ /? �T FOR DEPARTMENT L14E ONLY Appl vation Accepted by Area ❑ Stk 466-6781 Additional Comments: Lo 369-3621 Pit or Grout Inspection by Date LJ Manteca 823-7104 Final Inspection by _ Date L Tracy 835-6385 Applicant - Return all copies to: Envi nmental Health Permit/Services 1601 E. azeltcn Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO G Q ao 1 EH 13-24 REV. 10/82 cl 4 7 10/82 500 14-26 ro I