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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ° f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED I PERMIT EXPIRES I YEAR FROM DATE ISSUED k (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 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7. �( , iF/G10�,il�Iy Ste /Subdivision Name Owner's Name "R:09_1��[Z� ��(_Address '_-:9AA4E Phone Z-04-+2- i Contractor's Name' �,� G�®�� License No. Phone 4lra(n TYPE OF WELL/PUMP WORK: NEN WELL p WELL REPLACEMENT DESTRUCTION ❑ W PUMP INSTALLATION SYSTEM REPAIR t OTHER EJ DISTANCE TO NEAREST: SEPTIC TANK ] SEWER LINES DISPOSAL FLO. PROP. LINE --- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a Industrial E]Open Bottom Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing LE] Public 71 Other ❑ Delta Type of Casing u Irrigation Approx. [] Eastern Depth ,. Specifications. .4 _ Cathodic Protection _ Depth of Grout Seal Geophysical Type of Grout Q"} {_l Other Surface Seal Installed by d Repair Work Done Q Type of Pump H.P. State Work Done �+ Well Destruction ❑ Well Diameter Sealing Material (tap 501) Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is T available within 200 feet.) Installation will serve: Residence 4-- Commercial _ Other ENumber'of living units: Number of bedrooms -- - Lot size + Character of soil to a depth of 3 feet: Water table depth SZ) _ SEPTIC TANK Cj Type/Mfg Capacity 'No. Compartments _ PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Septic Tank Q Distance to nearest: Well Foundation Property Line Destruction LEACHING LINENo. & Length of lines / I Total length/size FILTER BED Distance to nearest: Well Foundation Property-Line 1 SEEPAGE PITS Depth :7� Size 4161W M v Number SUMPS ----- —Distance to nearest: Well ga Foundation �v• Property Line S { 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 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 s issued, I shall employ/persons subject to workman's compensation laws of California." The appl an all ar all re fired i spections. Complete draw i n reverse side. Signed Title: Date: ORD ARTMENT USE ONLY Application Accepted by Area G Z s® Stk 466-6781 Additional Comments: E:] Lodi 369-3621 Pit or Gralft Inspection by Date Manteca 823-7104 Final Inspection by Date /-S- XL,— Tracy 835-6385 Applicant Return all copies to; Environmental Health PerIL /Services 1601 E. HaieltohlAve., P.O. Box 2009, Stk., CA 95201 k FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I j13 EH 13-24 REV, 10/82 10/82 500 II 14-26 »,•