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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E ��71 y . HAZELTON AVE., STOCKTON, CA PERMIT NO. Al! ` L Telephone (209) 466-6781 DATE ISSUED Ili PERMIT EXPIRES 1 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 Regulation's lof the San Joaquin Local Health District. � Job Address 62 �, zf/ P Subdivision Name a <D Owner's Name r ( �r77 Address fa 4 `T LS i Phone Contractor's Nam °ea s� ;1r,Nk Co License No.,3zVZ ZCa Phone3&2-5 10Sc TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial Open Bottom []Manteca Dia. of Well Excavation L7 Uomestic/Private Gravel Pack Tracy Dia, of Well Casing Public Other Delta Type of Casing U Irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction-U.--Well Diameter Sealing Material (top 501) - Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of edrooms Lot size f Character of soil to a depth of 3 feet: Water table depth ^� SEPTIC TANK Type/Mfg Capacity No.-.Compartments - PKG. TREATMENT PLT. Type/Mfg Capacity v Method of Disposal Distance to nearest: Well Foundation --- Property Line LEACHING LINE [f No. & Length of lines Total length/size FILTER BED F_� Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size _ ' y' 10 Number f SUMPS Eil' Distance to nearest: Well IQD/ Foundation L:5-'I _ Property Line l d 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� 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 Inmust c 1 f all required inspections. Complete drawing o reverse side. Signed X Title: - Date: FOR DEPARTMENT U E ONLY Ap a#ion Accepted by� �7, n..!5e � Area Z Stk 466-6781 Additional Comments: �� ja Lodi 369-3621 Pit or Grout Inspection by Date C Manteca 823-7104 Final inspection by Date i 0 Tracy 835-6385' Applicant - Return all copies to: Environmen al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO . I - I . I ,�L//W y?� y--)---7-)L q EH 13-24 REV. 10/82 10/82 500 14-26 J