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AP,PLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,'STOCKTON, CA PERMIT NO. 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 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 7 E. y Subdivision Name 14'1 fOwner's Name �/ dress l Phone C3 Contractor's Name License No. Z 41 41 5 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT—Q� \DESTRUCTION U 06 PUMP INSTALLATION rL SYSTEM REPAIR OTHER' Lti DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE yU I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION5 J Industrial i pen Bottom Manteca Dia. of Well Excavation J mestic/Private Gravel Pack Tracy Dia. of Well Casing } ❑ Public � Other Delta Irrigation ' Type of Casing k L_j g Approx. 0 Eastern ZO e.4 L Cathodic Protection Depth Specifications el Depth of Grout Seal L Geophysical ' Type of Grout L Other yp - Surface Seal Installed by Repair Work Done G; Type of Pump H.P. State Work Done f Well Destruction L Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 1P TYPE_ OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION L (No`septic tank or seepage pit permitted if public sewer is fa, available within 200 feet.) #` Installation will serve: Residence i Commercial,;��, Other Number of living units: Number�of bedrooms .Z. i Lot size Character of soil to a depth of 3 feet: Water. table depth SEPTIC TANK i Type/Mfg Capacity .r'No. Compartments' PKG. TREATMENT PLT. [] Type/Mfg °M1 ' Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: WeiI Foundation" Property Line DESTRUCTION ❑ , s ' LEACHING LINE L .,. .No. & Length of lines . Total length/s'ize. i r FILTER BED # Lj Distance-to-nearest: Well Foundation __Property Line F -- SEEPAGE PITS ' ❑ Depth .Size-�_." FNumber SUMPS Distance to nearest: Well Foundation Pro perty,;Line 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.- , LI Home owner or licensed agent's signature certifies the following: "I certify that in the per'fo'rmance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmans 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 st call for all�rce�qui�redinspe s. Complete drawing on reverse side. fG Signed X .�/l/C - Title: Date: F DEPARTMENT USE ONLY Application Accepted by J f, Area Stk 465-678 Additional Comments: &Its= .fKLLA4 rv} 'Lodi 369-3621 j Pit or Grout Inspection by , Date L,Manteca 823-7104 Final }Inspection by __ Date L Tracy 835-6385 Applicant - Return all copies to: . 'Envi mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ;BASE AMOUNT DUE AMOUNT REMITTED c. -RECEIVED BY -� DtATE\� PERMIT-NNO. i INFO a� F EH 13-'24 \„REV. TO/82' �.�: �"" . 4 J 10/82 500