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i r A APPLICATION FOR PERMIT SAN ,OAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Of Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made-tol 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' o the San Joaquin Local Heal Cjstrict, m _ l/ �yy Jab Address 0 Subdivision Name /(k/ C-�J1 W Owner's Name 71 RA it? ,_If P e, ddress S AA-1 f— Phone q Contractor's Name 1�� UV � �is'Ici ense No. f:' ePhone .h , d I TYPE OF WELL/PUMP WORK: I NEW WELL WELL REPLACEMENT - DESTRUCTION ❑ N a PUMP INSTALLATION SYSTEM-REPAIR �: OTHER U J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES iDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I'LTYPE OF WELL PROBLEM AREAL CONSTRUCTION SPECIFICATIONS . J Industrial U Open Bottom El Manteca -Dia,of Well -Excavation ❑ Domestic/Private H, Gravel_Pack F-1TracyDia. of Well Casing 1-1Publicij Other Delta 1°_ " I Type of Casing F, Irrigation II Approx. Eastern M Cathodic Protection 'Depth Specifications Depth-of Grout Seal 1-1 Geophysical } U Other � Type of Grout -Surface Seal Installed by i# .Repair Work Done [] Type of�Pump H.P. ' State Work Done _ ! Well Destruction U Well Diameter Sealing Material (top 50') Depth Fi11er Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is V�.. IM available within 200 feet.) Installation will serve: Residence/ Commercial _ Other F —rAoo/_ R- (&ti"Alr 01 Number of living units; Number of bedrooms �- Lot size CTI Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg /�'� /a1 Capacity ,2.0 0 No. Compartments �-� PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal , SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line Q DESTRUCTION ❑ II {1 LEACHING LINE U No & Length of lines Notal length/size �[ # FILTER BED Distance to nearest: Well Foundation Property Line ! r SEEPAGE PITS Cf Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ],hereby certify that I have�.prepared this application and that the work will +e-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 1 .permit is issued, I shall not employ any person in such manner as to become subject to workman Is compensation laws of California." II Contractor's hiring or sub-contracting the following: "I certify that in the performance of the work for which ! this permit i issued, I,sha11 emplo ersons subject to w rkman's compensation laws of California." The applican m 11 for all eq 'red i ections. Complete dra ing reverse `ide. (, Signed Kit Title: Date: �� EPARTMENT US NLY Application Accepted by rf Area 5tk 466-5781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date E] Manteca 823-7104 i Final Inspection by � Date `/G—4f.? ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pe it/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk.; CA 95201 II. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ' j EH 13-24 REV. 10/82 10/82;-500� w � C.�ec� 14-2b - - I y,�