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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Requl�t ns of the San Joaquin Local Health D1t Job Address_ "~ �iTubdivission�a Owner's Name _ Tfllii ��— Address-- S/L`w dK- Phone Contractor's Name gli FLicense No. 7 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑r _ DESTRUCTION FJ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC .TANK" SEWER LINES DISPOSAL FLD. PROP. LINE V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SOMPS T INTENDED USE .. TYPE OF WELL PROBLEM AREA +�-� CONSTRUCTION SPECIFICATIONS Industrial Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing Public Other Delta Irrigation Irri Type of Casing U g Approx. -,,.❑,Eastern ❑Cathodic Protectyon-- Depth y Specifications f EJ Geophysical Depth of-Grout Seal Q , t ❑Other Type of Grout -- �` Surface Seal Installed by Repair Idork Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') w TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION D (No septic tank or seepage,pit permitted if public sewer is Y Installation will serve: Residenceommercia] Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a dep h of 3 feet- _A 6 y Water table depth z SEPTIC TANK Cj Type/Mfg ". Capacity a;� No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg _ _ - CapacityMethod of Disposal SEWAGE SYSTEM Distance to nearest: Well PFoundation _�p` Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines (}TS Total length/sizeU FILTER BED Distance to 'nearest: Wel] IAQ 1 Foundations Property Line SEEPAGE PITS Depth Size Number ! SUMPS ❑ Distance to nearest: Well Foundation Property 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. Home owngr or licensed agent's signature certifies the following: "I certify that in the performance-Df 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 must 1 Hred a'Apections. Complete drawing on reverse side. Signed X / �a� Title: ' Na Date: FOR DEPARTMENT USE ONLY Application Accepted by Area F-1 Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date -- Manteca 823-7104 � Final Inspection by Date /l/ L Tracy 835-6385 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environm - FEE BASE AMOUNT DUE AMOUNT REMITTED - "RECEIVED BY DATE - PERMIT N0. -- INFO d , dlz� 'EH'13-24 . REV. 10/82 _ 10/B2 500 14-26