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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 off- 3 Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 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 /y74q l/, yep, LODE Subdivision Name Owner's Name _3(3�a 7-R!/Ck '.4117D DUtg,�Address SAntc Phone Contractor's Name 1=l.0yam , I�OeF7> License No. .f,�j,Z7(� Phone i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F-] DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r A` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V` Industrial (] Open Bottom [__1 Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack F_� Tracy Dia. of Well Casing Public f-1 Other ❑ Delta Irri ation Type of Casing L V 9 Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal F-IGeophysical Ll Other Type of Grout Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') -- Depth Filler Material (Below 50') L J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other � S./' 7 Number of living units: Number of bedrooms Lot size $�A eoe-�S Character of soil to a depth of 3 feet: -ZeAlPt 11� Water table depth Ig 7 SEPTIC TANK Ee Type/Mfg L Capacity '9tlp No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal Distance to nearest: Well J,dfl-of- Foundation y U" Property Line 2-e7 LEACHING LINE U No. & Length of lines Total length/size „2C. V J, o/ FILTER BED Distance to nearest: Well 2,0,4 4- Foundation' IeVyl- Property Line /O SEEPAGE PITS [) Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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." The applicant must call f r all required i pections. Complete drawing on reverse side. Signed X C Title: l Date: �./ DEPARTMENT USE ONLY l Application Accepted by Area /Z F-1 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date j - L Tracy 835-6385 Applicant - Return all copies to: Environm ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26