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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA2ELTON AVE., STOCKTON, CA PERMIT N0. Q pi-t-/� f-L-- Telephone (209) 466-6781 DATE ISSUED \p PERMIT EXPIRES i-YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San Joaquin Local' Heal th 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 Joaquin Local Health District, Job Address /�`/�� ✓��wc `�C�c� Subdivision Name Owner's Name e Address lg/®/ 7�G Phone Contractor's Name ' License No. 3A2 x _ _ Phone TYPE OF WELL/PUMP WORK: m NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 1d ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial t U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private L] Gravel Pack Tracy Dia. of Well Casing �] Public E] Other _.C�] Delta Type of Casing Irrigation Approx. Eastern Depth �- Specifications r-le Cathodic Protection P pepth of Grout Seal Geophysical Type of Grout � U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done p Well Destruction U Well Diameter Sealing Material (top 50') Depth �j. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITIONj J {No septic tank or seepage,.pit-permitted if pub,l_i.c+sewer is a available within 20O.feet.) a� Installation will serve: Residence _ Commercial Other I Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth./ka!�171_ SEPTIC TANK Cj Type/Mfgl�ts.� ( Capacity No. Compartments �f PKG. TREATMENT PLT. Type/Mfg Capacity Method.of-Disposal l SEWAGE SYSTEM Distance to nearest: Well Foundation ProprtyLine DESTRUCTION LEACHING LINE LJ No. & Length' of lines - Total length/size R FILTER BED Distance to nearest: Well A'�,. Fourdation ,f Property Line SEEPAGE PITS Depth [ Size !,� r Number.X 3 SUMPS Distance to nearest: Well foundation. Property Line - DISPOSAL PONDS ❑ + ! r I hereby certify that I have prepared this application and that the work.wil4,bg 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 thef o 3_pwing,_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 t'o orkmant 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 t call for all wired in spections. s Complete drawing on reverse side. ,ze Signed X pA�.r' =GAS Date: Z � 7 ; � F DEPARTMENT USF LY - -- --w,_Application-Accepted by-- Area 01- a _�, -Stk. _ --0.66-6181,x -Ad itional Comments: Lodi 369-3621 Pi,or Grout Inspection by) ~,Date Tz Manteca 823-7104 Final Inspection by --- -Date ._ r YAZ L -T.racy.__ 835-6385 Applicant - Return all copies to; Fn vironmenta1 ealth Permit/Services 1601 E. Hazelton P.O. Box 2009, Stk., CA 95201 rINFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. !, EH 13-24 REV. 10/82 10/82 500 14-26