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L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT {� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �I�7 Telephone (209) 466-6781 / DATE ISSUED Y PERMIT E%PIRES 1 YEAR FROM GATE ISSUED (Complete in Triplicate) LApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 (a)ndd R ul ati-ons o�f1"the �'San i—Joaquin Local Health District. Job Address 7 ( i�, f�,�uu�`r1c�C.- A , Subdivision Name LOwner's Name ` —Address 7 Phone ?j J -Op Contractor's Name License No. Phone LTYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT E] DESTRUCTION [] PUMP INSTALLATION SYSTEM REPAIR E] OTHER 0 J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Fl Industrial ❑Open Bottom Manteca Dia. of Well Excavation L ❑ Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta Type of Casing (J Irrigation Approx. Eastern L Depth Specifications Cathodic Protection Depth of Grout Seal [�Geophysical Type of Grout Other Surface Seal Installed by LRepair Work Done F] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is --9 Installation will serve: Residence _ Commercial _ Other ,,,,,,�� available within 200 feet.) 666 Number of living units: 0— Number of bedrooms ��}--- Lot size Character of soil to a depth of 3 feet: aaA Water table depth SEPTIC TANK E] Type/Mfg `� Capacity J',2Ut7 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED Distance to nearest: Well f ay Foundation Property Line i SEEPAGE PITS Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LI 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." The applican$,mysy call r ll required inspections. Complete drawing on reverse side. Signed X ` -- 'J ,dam Title: _(1'�a,^2.fi�._ Date: l6 Yom. MENT USE ONLY Application Accepted by �/r X17 ,' Area e•Z Stk 466-6781 Additional Comments: Lodi 369-3621 ` Pit or Grout Inspection by Date Q Manteca 823-7104 Final Inspection byj/./ Dater .a Tracy 835-6385 Applicant - Return all copies to: Environmen4raf Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 h 4/ FEE BASE AMOUNT DUE I AMOUNT REMITTED RECEIVED BY I DATE PERMIT N0. .V INFO �1 // 1� `�'� / a3 8 a- 73 77 L EH 13-24 REV. 10/82 61- 66" � / �f 10/82 500 14-26