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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT -^Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED S 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 w6V* he n described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1867Ifor�)1/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 013 1 tWP_MA0 AV IS Subdivision Name Owner's Name CHAIR & Address q$( Qo9- AN Ar'1) = Phone Contractor's Name \,//, License No. Phone -) TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR OTHER 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 SPECIFICAT Industrial U Open Bottom Manteca Dia. of Well Excavati I_IDomestic/Private ❑Gravel Pack Tracy Dia. of Well Casing I= 16 Public F-1 Other Delta Type of Casing V Irrigation Approx. E] Eastern Specifications F—ICathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done -Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units:51;y , mber of bedrooms :? — Lot size �-� --� Character of soil to a depth of 3 feet: 10 Water table depth SEPTIC TANK T!(- Type/Mfg<OUC Q£[ Capacity No. Compartments Z PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well I S Foundation 2Q of Property Line DESTRUCTION LEACHING LINE No. & Length of linesT Total length/size FILTER BED Distance to nearest: Well Foundation —LTC—, Property Line (ems O SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C�l�oU � W 1(( (pl'� 7 (��/ frca�vl 5E'(o�C. �,.�.{�G �2c� 4 ,ao 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 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 of California." Thea licant u t call r all re ired inspections. Complete draw' on reverse side. SignedpX .� � p Title: =, Date: 41[ 0 PARTMENT SE ONLY Application Accepted by Area03 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b�,i _ Date Manteca 823-7104 Final Inspection by Date Z S ❑ Tracy 835-6385 Applicant - Return all c to: Envir ent Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO -71 EH 13-24 REV. 10/82 �/� 10/82 500 14-26 "�1