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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT �` + �i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Vi Telephone (209) 466-6781 DATE ISSUED ko 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 /D/ ,�/$tL: ,E?� Subdivision Name ownerI s Name 4,0 Address J�1/D/ w�-� �L Phone Contractor's Name " r A4W License No. Phone TYPE OF WELL/PUMP WORK: T NEW WELL r r� WELL REPLACEMENT ❑ DESTRUCTION - PUMP INSTALLATION SYSTEM REPAIR DTHER jJ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial ' U Open Bottom ❑Manteca Dia. of Well Excavation L_I Domestic/Private ]Gravel Pack D Tracy Oia. of Well Casing Public jOther L:]Delta Type of Casing lJ Irrigation Approx. Eastern e-- Specifications F—J Cathodic Protection Depth 1 Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Worx Done Type of Pump H.P. State 'Work Done Well Destruction Well Diameter Sealing Material (top 50') x: Depth moi. Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONj J (No septic tank or seepage rpit-per.mi,tted if pu`b,i-i.c-sewer is Q available within 200-feet.) Installation will serve: Residence _ Commercial !! OtherI Number of living units: Number of bedrooms Lot size -y Character of soil to a depth of 3 .feet: ��' Water table depthA4e SEoTIC TANK Type/Mfg Capacity P No. Compart.arments -= PKG. TREATMENT PLT. Q Type/Mfg -� Capacity Method•_pf'OisposaI SEWAGE SYSTEMDistance to nearest: Well /ate Foundation � Property,.Line DESTRUCTION . 0 LEACHING LINE No. & Length of lines - Total length/size FILTER BED Distance to nearest: Well Fourdation /Property Line SEEPAGE PITS Depth Site J��&4-lj0`,t Numbers!" SUMPS LJ Distance to nearest: Well -� oundaEion. Property Line mss DISPOSAL PONDS ❑ ., + '" I hereby certify that I have prepared this application and that the work,wili',bg dohin'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,oj)owjng: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manne"r as to-5ec'ome subJec-t o'£'�workman 5 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 t call for all aired inspect Signed X �T�•tlions. + Complete drawing on reverse side. -'X � -- - Date: . 2 e:--•-°^- 5LPDEPARTMENT USE LY --:::Application-Accepted by - Area Additional Comments: Lodi 369-3621 t or Grout Inspection by��J�_ 27Date Manteca 823-7104 Final inspettion by --T�� --- -Date -b�. .Tracy.-- 835-6385 ». Applicant - Return all copies to:. Environmental ealt Permit/.Services 1601 E. Hazelton U., P.O- Box 2009, Stk., CA 95201 . 71NFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. I S, EH 13-24 REV. 10182 1D/82 500 3 14-26