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APPLICATION FOR PERMIT - SAN JOAQUiN LOCAL HEALTH DISTRICT a 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) s 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 f the San Joaquin Local Health District. Job Address SSZ2z c ® y, Subdivision Name Owner's Name Address /Z Z9_ A Phone Contractor's Name License No. Phone -S60Q71 TYPt OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ J PUMP INSTALLATION ❑ SYSTEM REPAIR �� ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OISP0SAL .FLO. PROP. LINE I FOUNDATION = A51•CULTURE_-WEL•L OTHER WELL PITS/SUMPS INTENDED ISx est TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca £ Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well .Casing y�9i„❑ _ {❑ Public Other, i _ ❑ Delta _ .�'9 �.. >{ � Type of Casing Irrigation Approx`. [] Eastern . Specifications ❑Cathodic Protection Depths IV �- Depth of Grout Seal ` Geophysical }� v - Type of Grout o ❑Other, w Surface SeaOlnstalled by Repair Work Done FJ Type of Pump /` H.P. State Work Done Well�Destruction lJ�f-'Wel1,.Diameter- - .o Sealing Material (top 50') ! - Depth f Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITI N (No.septic tank or' seepage pit permitted if public sewer is 1 available within 200 feet.) t Installation will serve: Residence [ Commercial Other ! Number of living units: �_� Number of bedrooms Lot size{! Character of soil to a depth of 3 feet: � I ' Water table depth , I IN SEPTIC TANK F-1Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. Type/Mfg r-,3 eCapacity Y Method of Disposal SEWAGE SYSTEM Distance to"nearest: Well Foundation Property tine �;} (DESTRUCTION LEACHING LINE No. & Length of lines 'Total.length/size 5 FILTER BED ❑ Distance to nearest: Well 4 Foundation t-e947 - property Line De th Number t SEEPAGE PITS, F�_ ,__ .P._� E � Size SUMPS Distance to nearest: Well Foundation, �- Property Line _, DISPOSAL PONDS ❑ M �. I i � 71 )' 1 hereby certify that,I have prepared this-application and' that the work w}.11 be done in accordance with San Joaquin county ordinances; state`haws; and rules and regulations of the San Joaquin Locail-iiealth 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 i ed, I Shall n'ot employ any pe on in.such..manner as to become-subject to workmans compensation-laws of California." Contractari irin or sub-contracting'si' ature certifies, Ife.(follawing: '.'I certify that;in-the-,perormanceMo -t hetwork,far-whish_ this permi is i ed, I shal employ ons ubject tv I�. an+s compensation laws of Coliform a." The appl' a 11 for l re r ins ec 'ons. Com 1 on.reverse,side. ' Signe - - - Title: "" Date: w - T R APARTMENT ti ONLY -Aresk 466-6781 Application Accepted by �" J° 4 f El Lodi 364-3621 ,l. Additional Comments: Date Manteca 823-7104 r Pit or Grout Inspection by 4 > Date - Tracy 835-6385 Final Inspection by lr(f Applicant - Return all c o: Environmental Hea h'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 952D1 RECEIVED BY DATE PERMIT NO. } FEE BASE AMOUNT DUEAMOUNT REMITTE➢ F �,._..-.....-.i-- -INFO' _-._.- ---- ��---. - '�.: !_z-.. �. �� ' l�/ .r,,,,��tee. � `�;'..'�..• /'� {p ��4 !0/.82-500- EH 0%82.500„..-..-...,---... a. -13-24-REV. 14-26 `4 a