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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Z�&-lbq ! Telephone (209) 466-6781 3 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete ,in Triplicate) r. 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 �_?-,�,yjj � �y. b.Z� r. %&�Subdivision Name Owner's Name £ Address Phone Contractor's Name License No. Phone 11"_7Lor) I N. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL .;OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRTICTION SPECIFICATIONS ❑ Industrial [] Open Bottom [Manteca Dia. of Well Excavation r, U Domestic/Private F-1 Gravel Pack _ []'Tracy Dia.-of Well Casing Public [1 Other ❑ Delta Type of Casing [j Irrigation Approx. ❑Eastern Cathodic Protection Depth Specifications „w Depth of GroutSeal ❑Geophysical Type of Grout - 0; ❑Other Surface Seal Installed by Q _ Repair Work Done [] Type of Pump H.P. State Work Done Q Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other ` Number of living units: � Number of bedrooms -13 Lot size Character of soil to a depth h of 3 feet: Water table depth C.i.�f9ZCa�+ SEPTIC TANK ` Type/Mfg Capacity /.`�.Qa No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation �_ Property Line /p � - ^�' DESTRUCTION ❑ LEACHING LINE No. A Length of lines Total length/size o� FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth cY'j_ Size �� Number 5j SUMPS ❑ Distance to nearest: Well �/�� Property Line Am 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 owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this h manner as to become subject to workmanIs compensation laws of California." permit is issued, I shall not employ any person in suc ' fies the following: "I certify that in the performance of the work for which Contractor's hiring or sub-contracting signature certi this permit is 'sued, I shall empl persons subject to workman's compensation laws of California." The applic call all uire spec 'ons. Complete d�r�/y/jp/g on reverse side. Signed .`Q/ Ij Title: . � Date: fis (J [ / DEPARTMENT USE ONLY Area Stk 466-6781 Application Accepted by , � Lodi 369-3621 `I Additional Comments: ❑ Manteca 823-7104 Pit or Grout Inspecti4to::AEnvironmenta Date Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie Health Permit/Ser ices 1601 E. Ha elton Ave., P.O. Box 2009, Stk., CA 9520 DATE PERMIT PERMIT NO. j FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 1 10/82 500 EH 13-24 REV. 10/82 14-26 i 001 U: r J c J i ! !