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1 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -_7 Telephone (209) 466-6781 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 3252 Subdivision Name 4,ceakee- Owner's Name �'gyc, �pp n Address S Phone Contractor's Name ,gR as.5i License No. 2s—y-3 y Phone y96o TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ 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 SPECIFICATIONS J Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation F-1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing �] Public ❑Other ❑ Delta A Ll pprox. Irrigation Eastern Type of Casing 9 � ❑Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW 1NSTALLATIONX REPAIR/ADDITION ❑ (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: Number of bedrooms Lot size Character of soil to a depth of 3 feet: water table depth SEPTIC TANK ❑ Type/Mfg �o/11G. AA. Cie Capacity 2Nco No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE U No. 8 Length of lines Total length/size FILTER BED [] Distance to nearest: Well Foundation Property Line SEEPAGE PITS ® Depth 7,S'' Size �8 � Number IV SUMPS Ll Distance to nearest: Well Foundation --^ Property Line 4E _ DISPOSAL PONDS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county C 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 for all requi^ d inspections. Complete drawing on reverse side. Signed x Title: � .� a� Date: '29`83 'FOR DEPARTMENT USE ONUY. Application Accepted by 007d AiQ rea 40Z ( •Stk 66-6781 Additional Comments: Juc.c. oL� [� Lodi 36 21 Pit or Grout Inspect' n by �L Date T �� Manteca 823-7104 Final Inspe � ction by fl{ �. Date V0_ Tracy 835-6385 Applicant - Return all cope o: Environmental 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. LA1NF0 EH 13-24 REV. 10/82 4f 'Md/T/MJ✓; Ale A,, ,W�G✓� t�/ �i�w.+�iJ c�..�B,zc/+ c.�ws��.}0/82 500 14-26 '7K4s� by ,r t, ha— 'ex's k+I-.