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APPLICATION FOR PERMIT SAN JOAQU;N LOCAL HEALTH DISTRICT Q?? 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. r Telephone (209) 466-6781 G� 7 DATE ISSUED / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin local Health District fora 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. 188622 for weillll/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address :R�Yb 711:- P-et Subdivision Name ■. Owner's Name �^ C/� Address Phone Contractor's Name u n 174a License No. `3 6 79 Phone Q I 7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C IJ Industrial Open Bottom ❑Manteca Dia. of Well Excavation LJ F-1 Domestic/Private E]Gravel Pack []Tracy Dia. of Well Casing C4 ❑ Public Cj Other []Delta Type of Casing Fj Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout - Other Surface Seal Installed by Type of n � Repair Work Done �J Pum H.P. State Work Done p Well Destruction ❑ Well Diameter Sealing Material (top 50') (� Depth Filler Material (Below 50') P� TYPE OF SEPTIC WORK: NEN INSTALLATION I t- REPAIR/ADDITION ❑ (No septic tank or seepage PiLAI avaelableewithiif nu200cfeete)is Installation will serve: Residence _ Commercia1 4 Other Number of' bedrooms Lot size Number of living units: Water table depth Character of soil to a depth of 3 feet: 7 e Mf n��^ Capacity _ No_ Compartments SEPTIC TANK X yp / 9 Capacity Method of Dis�jjal PKG. TREATMENT PLT. Type/Mfg - ll�l ndation Property Line v r.. SEWAGE SYSTEM C] Distance to nearest: Well 11 �i DESTRUCTION 1110l Total length/size LEACHING LINE No. & Length of lines Pro Distance to nearest: Well Property Line Foundation p FILTER BED i Depth Size �t2 -- Number SEEPAGE PITS Foundation Property Line SUMPS Lj Distance to nearest: Well DISPOSAL PONDS D ordinancesreby erstatetlawsi aderulesaa d regulatPonsaof theand Santhat Joaquinwork Localwill Health District. e done in accordance with San Joaquin county 1 an person in such manner as to become subject to workman compensation laws of California."i 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 Y P ` Contractor's hiring shall sub-contracting signature certifies the following: "I certify that in the performance of the work for whit this permit is issued, I shall enploy persons subject to workman's compensation laws of California." � The applicant mus all for all r wired inspecti S. Complete drawing in`reverse side. - Date: Title: 99 YY�� I/ Signed XIn Q� ` R PART1 � USE ONLY 466-678 Area Stk Application Accepted by Lodi 369-3621 Additional Comments-. _Date 3 L] Manteca 823-7104 Pit or Grout Inspection by Date Tracy 835-6385 Final Inspection by Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 RECEIVED BY DATE PERMIT N0. 6"' FEE BASE AMOUNT DUE AMOUNT REMITTED ,p j y� INFO , 0 3 l BV� :S' /_3f 10/82 500 6` EH 13-24 REV. 10/82 14-26