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t.. APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, 0 47' `► / Telephone (209) 466-6781 DATE ISSUED . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein described., This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or RD. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District,. , " Job Address X 9 -_ �- cJr,� . Subdivision Name Owner's Name d,;1Y,1-4 P,9 �f�-7' of Address �3�` ( r�r�►� e - SG«mar Phone R3 0- 4 8 Phone Contractor's � /6� ,Name . *l1>eeY � SP/�/ License No. TYPE OF WELL/PUMP WORK: NEW WELL C] WELL REPLACEMENT DESTRUCTION [J PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPEIOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ttD Industrial ❑Open Bottom fJManteca Dia. of Well Excavation Domestic/Private E]Gravel Pack Tracy Dia. of Well Casing Public F-i Other Delta Y� pe of Casing U Irrigation !Approx. E] Eastern Specifications Cathodic Protection ,Depth f � � Depth of Grout Seal f Geophysical Type of Grout Other Surface Seal.Installed by Repair Work Done Q Type of Pump H.P. State Work Done Well Destruction EJ Well Diameter Sealing Material (top 509 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) G " Installation will serve: Residence X Commercial _ Other t r Number of living units: ' Number of bedrooms 3 Lot size Character of soil to a depth of 3 feet: Water table depth S SEPTIC TANK Type/Mfg �: �.r?/Svs� of sdN Capacity j koo No. Compartments x PKG. TREATMENT PLT: Type/Mfg Capacity Method of Disposal .Distance to nearest: Well -4-10 Foundation Property Line 49 LEACHING,LINE PJ No. & Length of lines Total length/size J C A FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [] Depths_ Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L—I 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 workman compensation laws of California." ontractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which p this ermit is issued, I shall employ persons subject to workman's compensation laws of California." 4 'r The applicant m st call for all required inspections. Complete drawing on reverse side. _ Signed X Title: GOyi ��-f Date- ORDEP MENT USE ONLY Area Stk 466-6781 Application Accepted by Additional Comments: [] La369-362.1 Pit or Grout Inspection by Date _ �' Mann teca 823-7144 Final Inspection by �. Date ��7 - "� ( 09 Tracy 835-6385 Applicant - Return al]4.capias to, Environment Healt ;Permit/Services 1601 E. ,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE 'AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. INFO . l l vs115-(471 10/82 540 EH 13-24 REV. 10/82 _ -� L+ 14-26