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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA IT NO. Telephone (209) 466-6781 ISSUED 02 b Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE COPTE (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 Regulations of the San Joaquin Local Health District. Job Address / 7 N, NW V L?9 • ` Subdivision Name Owner's Name Address P0. &OX Phone Contractor's Nam License No.3c 22 _ Phone,1�? —5-7 0 p�) TYPE OF WELL PUMP WORK: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION 4 PUMP INSTALLATION SYSTEM REPAIR E OTHER U 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 Industrial EJ Open Bottom T_j Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack []Tracy Dia. of Well Casing 1-1 Public Other Delta Type of Lasing F-1 Irrigation Approx. [ Eastern Specifications Cathodic Protection — Depth Depth of Grout Seal Geophysical Other Type of Grout - Surface Seal Installed by" Repair Work Done Q Type of Pump N.P. State Work Done Well Destruction 0 Well-Dfameter, Sealing Material (top 501) - Depth Filler Material (Below 50') _ .J TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION E (No septic tank or seepage pit permitted if public sewer is ,J Insta7latian will serve: Rekideavailable within 200 feet.) Number _ Commercial Other Cf1 Number of living units: Number ofrooms Lot size,c2Q Character-of sail to a depth of 3 feet: �}rt Water table depth _ Aj O T SEPTIC TANK Cj Type/Mfg ._Capacity No, Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal Distance to nearest.. Well Foundation Property Line LEACHING�L'INE L_.l No.}d Length of lines Total length/size FILTER BED Distance to nearest: Well ! Foundation Property Line SEEPAGE PITS Depth Size �j(D_ ?lumber 7 SUMPS I_I Distance to nearest: Wellew .Foundation l4 Property Line s+ DISPOSAL PONDS I hereby certify that Chave prepared this application and that the work will be done in'accordence with San Joaquin county ordinances, state-laws, and rules and regulations of the Sart 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 permit is issued, I 0fall not employ any person in such mannir as to become subject to workman§ 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,gf California." The applic nt must all for all required inspections. Complete drawing Qn reverse side. Signed ff Title: V Date: 12— FOR 2FOR DEPARTMENT USE ONLY �� .App ication Accepted by �� Area Stk 466-6781 Additional Comments: Lodi 364-362.1 Pit or Grout Inspection" Date C'l 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. INFO 5 EH 13-24 REV. 10/82 10/82 500 14-26 �4 Y