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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r l � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 �OiA \� Telephone (209) 466-6781 DATE ISSUED �� 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 and the Rules and Regulations of the San Joaquin Local Health District. Job Address_lA, $� S; J�-"X, XA) ef/6r�S>X.✓Subdivision Name Owner's Name Address -f4e!d—,r -� Phone S 9ys7 Contractor's Name License No. y�y7L Phone '54-A'— ?,9 71 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E-1 l PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial U Open Bottom Manteca Dia. of Well Excavation L7 Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta Irrigation Type of Casing Irri Ej 9 Approx. Eastern Specifications E] Cathodic Protection Depth 1-1 Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ice' (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _kI Commercial _ Other available within 200 feet.) Number of living units: �- Number of bedrooms 7i Lot sizes�4 X 11 0 . Character of soil to depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg — JagL 1. Capacity 17-00 No. Compartments 'Z, PKG. TREATMENT PLT. !] Type/Mfg Capacity _ Method of Disposal Distance to nearest: Well "7 Sl Foundation JQ Property Line .� LEACHING No. & Length of lines Total Tength/size FILTER BED �x�ff F-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS �yt/(s-Depth Size Number SUMPS FiJLl Distance to nearest: Well Foundation Property Line 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 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 required inspect' s. Complete drawing on reverse side. Signed X Title: Date: FOR DE M USE ONLY Application Accepted by Area 01AI Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Q Manteca 823-7104 Final Inspection by T Date ///,2 S t 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,-.CA 95201 J FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26