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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. q C! Telephone (209) 466'-6781 DATE ISSUED 3 3 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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressL ,� Subdivision Name Owner's Name _"AMS a Address SA&IE Phone 93J_4 4 7 Z.. Contractor's Name License No. XtC Z,74 Phone f4 a-3 9 7 _ h W TYPE OF WELLIPUMP WORK: NEW WELL F7 WELL REPLACEMENT DESTRUCTION CN -- -PUMP 4NSTALLATION.--SYSTEM REPAIR...,. E. .,—.—OTHER t DISTANCE TO NEA RES T: .SEPTIC TANK SEWER LINES- DISPOSAL FCD. PROP. LINE LFOUNOATION AGRICULTURE WELL OTHER WELL PITS/SU`MPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Dia, of Well Excavation Lf Domestic/Private ❑ Gravel Pack F_� Tracy, Dia, of Well Casing Public E Other Delta Type of Casing Lj Irrigation Approx. E] Eastern ~ Cathodic Protection Depth N , Specifications 17 Geophysical Depth of Grout Seal LJ Other Type of Grout Surface Seal Installed by Repair Work Done D iType of Pump H.P. I :State Work Done i Well Destruction U Well Diameter Sealing Material (top 50') ; _ - i Depth Filler Material (Below 50') --�- F 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 00" Commercial Other Number of living units: Nuaber of bedrooms Lot size /616FJr1 47 Character of soil to depth of 3 feet: eI Water table depth # - �-SEPTIC TANK Type/Mfg �� — f�¢L ` Capacity /z.-o c7 No. Compartments } 'L PKG. TREATMENT PLT. 0 Type/Mfg ?! + Capacity Method of Disposa l SEWAGE SYSTEM }Distance to"nearest:..-Well.....�,40 Foundation Property Line DESTRUCTION Q I R e LEACHING LINE & Length of lines , Total length/size I FILTER BED } Distance tolnearest:.Well.. " Foundation _ Property'Line � SEEPAGE PITS �7 h Size j Number SUMPS Distance to nearest: Well Foundati0n, - Property Line DISPOSAL PONDS C1 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. ! 1 Home owner or licensed agent's signature certifies the following: "Iicertify 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 EIaws 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." f The applicant must call for all required inspections. Complete drawing on�r.everse side, {¢ Signed X _ } i�, Title: , 4, Date: OR DE RTMENT USE ONLY # Application Accepted by le.� Area 4 Stk 466-6781 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 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I,D 5'J 3 EH 1324 REV. IO/B2 10/82 500 i 14-26 91 1