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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. t Telephone (209) 466-6781 DATE ISSUED -a0-9- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (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. V Job Address 2�EF N 7b *-- Subdivision Name Owner's Name -7&0 -TG .Wkr Address Phone Contractor's Name /4Hiay --Yc Sf License No. �,V-3413 Phone -s�6-?6T 7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION C] W PUMP INSTALLATION SYSTEM REPAIR OTHER [ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t1^' v ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial F]Open Bottom Manteca Dia. of Well Excavation L7 Domestic/Private [-]Gravel Pack Tracy Dia. of Well Casing L7 Public Cl Other Delta T ypeIrrigation pec of Casing F-1 9 Approx. �Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') ..� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION No septic tank or see �I U ( p page pit permitted if public sewer is Installation will serve: Residence X Commercial _ Other available within 200 feet.) Number of living units: _/ Number of bedrooms �_ Lot size �O /�, Character of soil to a depth of 3 feet: G� Water table depth /00 047A - SEPTIC TANK Type/Mfg ;; P r u -�Sor�S Capacity /2.0„ No. Compartments — 7-PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ^ Distance to nearest: Well '� Foundation _f-E> Property Line '21E> LEACHING LINE No. 8 Length of lines 71 - as- Total length/size FILTER BED Distance to nearest: well CV— Foundation _6_o Property Line r SEEPAGE PITS ® Depth _:Zl:::: Size 3-1" 2 Number SUMPS CJDistance to nearest: Well foo Foundation — Property Line DISPOSAL PONOS ❑ r. 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 permit is issued, I shall not employ any person in such manner as to become subject to workmanf 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;ca)l for all require spr tions. Complete drawiia on reverse e. L' Signed % Title: y_{�L'�y� Date: -7^Zo FO EPA TMENT USE ONLY Application Accepted by �. Area _�� Stk 466-6781 Additional Comments: 0 Lodi 369-3621 Pit or Grout Inspection byq� Dat:-4-cm f7 El Manteca 823-7104 Final Inspection by ,Up Y/a Date i+L'( y.-O�j_ 0 Tracy 835-6385 Applicant - Return all copies to: environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 bin FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 4 1,L0 73 254 o" EH 13-24 REV. 10182 10/82 500 14-26