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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 DATE ISSUED 4 9 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 Re ulati0nf of the San Joaquin Lo al Health District. Job Address 37 f�. V( '' Subdivision Name �/ Owner's Name e^ 4 Address sG�� Phone Fj j— ^y 37 Contractor's NamellrjAerN No. 1X066-6 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION r llk�SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �^ 1J-Industraal ,� .F_Open_Bottom ...��-Apia-=of Weli-Excavati'on�`'" '�- 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal I' Geophysical Type of!Grout J Other f Surface,Sea1 Installed by Repair Work Done E] Type of Pump 5(� H.P, State Work Done @ ta, C1A s Well Destruction ❑ Well Diameter Sealing Material (top 50') _ r Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic'-tank or seepage pit permitted if public sewer is 'I available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: +' Water table depth SEPTIC TANK ❑ Type/MfgP y p Ca acit '� No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity - € Method of Disposal , SEWAGE SYSTEM ci Distance to nearest: Well Foundation ;-+-�-- fP_r-oper_ty Line�__.� DESTRUCTION LEACHING LINE [j No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ) Property Line F I SEEPAGE PITS ❑ Depth Size Number -SUMPS Distance to nearest: Well Foundation 1 Property Line DISPOSAL PONDS ❑ i� � ; I hereby certify that I have prepared this application and that the work will be done injaceordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Hearth District.-_ I Home owner or licensed agent's signature certifies the fallowing: "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 is compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify thatein the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of Cal.i,fornia.�' "� e r The applica must call r a l re re inspections. Complete d awing ft reyerse side Signed X Title: Date: OEPARTMENT'USE ONLY d — Application Accepted by C Area , Stk 456-6781 Additional Comments: , �.-, ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date / � ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ]NFO S l f5 NSD -J�-�) g3-8 t3 EH 13-24 REV. 10/82 1 /�h 10/82 500 14-26 �W �L l��'