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i APPLICATION FOR PERMIT SAN JOAQU'i`, LOCA'_ HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERFIIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ` (Complete in Triplicate) i Application is hereby made to the San Joaquir 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 the San Jcaquir.Local Health District. Job Address u f?-mar Name Owner's Name Addres — k / Phone Contractor's Name A.Aacense No, Z$ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT CESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROF. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack Tracy Oia. of Well Casing Public [ Other Delta i — M Ljirrigation Approx. Eastern Type of Casing Depth Specifications [J- Cathodic Protection #P Depth of,Grout Seal ❑Geophysical ❑Other Type 91Grout ` Surface Seal Installed by Repair Work Done El Type of Pum r "`�� , Pump H.P. State Work Done_ ti_ Well Destruction ❑ Well Diameter Sealing Material',(top 501) Depth Filler Material (Below 50')x. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank-o seepage pit permitted if public sewer is Installation will serve: Residence Po" mm Caer` al _ Other available within 200 feet. > WA` �� Number of living units: —/- Number of bedrooms Lot site !- p7 Character of soil to a depth of 3 feet:/ Water table depth' ,� SEPTIC TANK Type/Mfg // ' Capacity 14,0e9 No, Compartments PKG. TREATMENT ?LT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION Foundation ��Z PropertyLiney ❑ SCG r4 - 1 k LEACHING LINE No. & Length of,,lines — yulk4- _ Total length/size 42 d Z.1— --- rw `� FILTER BED Distance,to nearest: Well p Foundation 'Property Line 1 > SEEPAGE PITS Depth ; Size Ze .1a 4A Number yj`. SUMPS Ll Distance to nearest: We.]1 Foundation 1,64tt0:1, Property Line DISPOSAL PONDS A. I hereby certify that I have prepared this application andthatthe worklwil.l 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.workmanK 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.".Z f � The applicant must call for all required inspections. Complete�drawing on`reverse side.' Signed x „l Title: _ �. ` Date: le— PARTMEN USE ONLY Application Accepted by Area , L] Stk 465-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date L � Tracy 835-6385- - Applicant - Return all copies to: En onmental Health Permit/Services 1601 E. Hazelton Ave—P.O. Box 2009, Stk., 'CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY r.r' DATE PERMIT NO. INFO -'1Sb`g4 - 1 EH 13-24 REV. 10/82 10/82 500 1 14-26