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APPLICATION FOR PERMIT `wI ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED _3 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump C and the Rules and Regulations of the an Joaquin Local .Health DDiisttri I Job Address /O��a�'/�/�,��"-�WQ ,�ldL_�. ' drvTs�� i� A Lay Owner's Name ddress /dIi// LRRsa>� fct�✓ PhoneOgq-2-11 T ` Contractor's Name N.t . + License No. Phone y&46!Sfid? 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 SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑Manteca Dia: of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy_ DiA: of Well Casing r ❑Public Uj Other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications _ ❑Cathodic Protection Depth Depth of Grout Seal ✓ ` [J Geophysical Type of Grout O L Other� 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X (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: -4_ Number of bedrooms 7, Lot size Character of soil to a depth of 3 feet: Water table depth /O SEPTIC TANK ❑ Type/Mfg .Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal C SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line {{' DESTRUCTION ` LEACHING LINEp;p No. a Length of lines t � � Total length/size la� 7 FILTER BED ❑ Distance to nearest: Well Foundation Js ' Property Line /O SEEPAGE PITS n Depth "7 Size T�� Number ` SUMPS Jf�ya Distance to nearest: Well � Foundation d64p a Property Line /O DISPOSAL PONDS ❑ .. 1 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 Q- permit is issued, I shall not employ any person in such manner as to become subject to workman S compensation laws of California." Contractor's h' ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i issued, I shall emplo pers subject to workman's compensation laws of California." The appli t call f all r red ns do Comple n reverse side. Signed X Title: �+.L%✓ Date: �-okk ` TMENT ONLY Application Accepted Area E] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Ll Manteca 823-7104 Final Inspection by T _ A Date 3 ❑ Tracy 835-6385 Applicant - Return all copi(s to: Environmental Hea Ah Permit/S rvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. L INFO EH 13-24 REV. 10/82 10/82 500 6- 14-26