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f APPLICATION FOR PERMIT SAN JOAQUiN LOCAL•HEALTH DISTRICT (� 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. I Telephone (209) 466-678I GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 Regulations of the San Joaquin Local Health District. Job Address 19L.L gyAK wealb Subdivision Name Owner's Name A2 gAe �' ZM- Address XAft1, Phone _ Contractor's Name �/� � 1a�i7� License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ W i PUMP INSTALLATION SYSTEM REPAIR U OTHER {DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE r + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation It U Domestic/Private C] Gravel Pack Tracy Dia. of Well Casing 117 Public ❑ Other ❑ Delta T L1 Irrigation Approx, E] Eastern Type of Casing Depth Specifications Cathodic Protection Depth of Grout Seal Geophysical Type of Grout ❑Other '► Surface Seal Installed by i Repair Work Done ❑ Type of Pump HSP. State Work Done _X) Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') 013 TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is i * available within 200 feet.) Installation will serve: Residence J� Commercial �Othe r Number of living units: Number of bedrooms Lot size Z e04? y IIA0 + i �� Water table depth Character of sail to a epth of 3 feet: +� _ p SEPTIC TANK Type/Mfg o- LL t 1 Capacity j X0 0 No. Compartments 12- PKG. PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: "- Well !f� Foundation -/Q Property Line } DESTRUCTION ❑ r LEACHING LINE No. & Length of lines ZF�� Total length/size FILTER BED Distance to nearest: Well `"fes Fovnifation /] Property Line SEEPAGE PITS Depth �_ Size 3 u t F Number SUMPS Distance to nearest: Well Foundation h/� Property Line DISPOSAL PONDS } 1 1 hereby certify that I have prepared this application andthatthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaiquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify thaf"in'the performance',of the work for which this permit is issued, I shall not employ any.personlin such mahner as to become subject tohworkmant compensation laws of California." Contractor's hiring or sub-contracting si"gnature:certifies the following: "I certify that in the—pe ormance of the work for which - this permit is issued, I shall employ persons' subject to workman's compensation laws of Califor ni a The applicant must call for 11 required ins p ctions.4 Complete`drawi g onsreverse side. '` Signed X Title-, Date: FOR D.EPARTMENT USE ONLY 1 Application Accepted by tt Area l _ Q"Stk 466-6181 Additional Comments: 1. ❑ Lodi 369-3621 Pit or Grout Inspection by 71 Date � El Manteca 823-7104 - Final lnspection by Date /,_�/G- �3 ❑ Tracy 835-6385 { 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2004, Stk„ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i EH 13-24 REV. 10/82 T 10/82 500 14-26