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APPLICATION FOR PERMIT SAN JOAQLIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3 E Telephone (209) 466-6781 DATE ISSUED r PERMIT EXPIRES 1-YEAR FROM DATE ISSUED, . ..f (Complete in Triplicate) Application is-hereby made to thelSan Joaquin Local Health District for a permit to construct and/or install jthe 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 Joaquin Local ealth.District. Job Address ubdivision Name Of oe 4 Owner's Name Z(� Address �i " Phone Contractor's Name I License No. f V Phone 4 TYPE OF WELL/PUMP WORK: NEW 1 WELL ❑ WELL REPLACEMENT,-] DESTRUCTION Ccs ,y III PJMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FED. PROP. LINE r i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Uel k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J ' ❑ Industrial ❑ Open';Bottom Manteca Dia. of Well Excavation U Domestic/Private ] Gravel Pack Tracy Dia, of Well Casing ❑ Public Other Delta❑ � ❑ Type of Casing IC Ljirrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications +� ..-m—DepthTof'=Grout'Seal ❑Geophysicall Type of Grout ❑Other Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done E Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 0 1&150')} 1�I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit Permitted if public sewer is 1!1available within 200 feet.) Installation will serve: Residence I_ Commercial _ Other —�D ' Number of living units: d # 1 Number of bedrooms Lot size d17 't, ! w 1{ Character of soil to a depth of43 feet: _ ® _ Water table depth" — V SEPTIC TANK Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Type/M'fg. Capacity Method of Disposal { SEWAGE SYSTEM Distance to ,nearest: Well Foundation 4 Property Line f' ! DESTRUCTION s: l i • LEACHING LINE No. & Length of lines $ Total length/size FILTER BED ❑ Distance tolnearest: Well Founllataion, Property Line g F SEEPAGE PITS ❑ Depth A Size # "V4NuAber r SUMPS ❑ Distance to nearest: Well Foundation �T , Property Line DISPOSAL PONDS ❑ 111 —"'••+- I hereby certify that I have prepared this application and that the work willp•be, done in accordance with San Joaquin county ; ' ordinances, state lawsand rulesl.and regulations of the San Joaquin LocalwHealth°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 applicant rnust call for all equired inspecti s.T Complete drawl on everse side. > Signed X Title: Date: �� ,/—g II F FPRTNENT USE ONLY ,�, , ? Application Accepted by Area C{r'.; /r.3 Stk 466-6781 { Additional Comments:. Lodi 369-3621 II Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date LL__d 3 ❑ Tracy 835-6385 Applicant - Return all copiesK] Envircnmertal Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FEE BASE AMOUNT ,DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0.FO EH 13-24 REV. 10/82 10/82 500 14-26 i