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APPLICATION FOR PERMIT " p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 , DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s; I (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_ A�, A 'fir Subdi vi sion Name sj9-v7-:s Owner's Name' �, tLv" -- ^r' , Address •; F .i t t `� Phone Contractor's Name t �fR�.�� License No. �' t ' "ti� Phone1/ _ --- TYPE OF HELL/PUMP WORK: NEW WELL T❑' WELL REPLACEMENI ❑ 'OESTRUCTION U _ " t _-w r `- - ) INST�LLAifON'� �SYSTEM'REFAIRy •� � OTHER U, ��._..__...r..•....�.�_ -____.._,�..._ DISTANCE)TO NEAREST: SEPTIC TANK SEWER LINES € DISPOSAL FLD•- PROP, LINE FOUNDATION II 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 TracyDia, of Well Casing ,i ❑ Publ i� �j Oth'r .�-� Delta ------I Type of Casing Irrigation Approx. ❑EasternSpecifications Cathodic Protection Depth Geo h sical Depth of Grout Seal P Y -.._..,- tipe of Grout Other �- Surface Seal Installed by c f• Repair Work Done �]' "Type of Puinp �""1 H.P. State Work Done Well Destruction )` Well DiameteF. ). 4 Sealing Material (top 50') . Depth II i J i Filler Material (Below 501: , TYPE OF SEPTIC WORK: NEW INSTALLAT 'ION REPAIR/ADDITION Li (No septic tank or seepage pit permitted if public sewer is i.s:_ 1 ' installation will serve: Residence Commercial _ Other tf ,..;,Number of living units:L Number of bedrooms Lot size 11 1 L , C��✓ 0 Character of soh il to 8 depth ofri3 feet: Dd^ f Water table dept ; SEPTIC TANK i Type/Mfg Capacity No.. Compartments PKG. TREATMENT PLT. ] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM 3 Distance to nearest: Well Foundation.. I Property Line DESTRUCTION ❑ j� ��— ` x LEACHINGiLINE� i 1 No.: & Leingth. of lines _t6--/40�O Total length/size' �j`—/D� �• FILTER BED t Distance to:nearest: Well Foundation Property Line SEEPAGE PITS i [j Depth 'ri ! Size Number 1f SL14PS > LJ � Distance`` to nearest: Well Foundation Property Line OISPOSAL,PONDS to / I hereby�certif,y that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rulesjand 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 penhit is fssued, ],shall employ persons subject to workman's compensation laws of California_" The applicant must call far alilrequIred inspections. Complete drawing on reverse side. ' Signed Xi Title: G�.�.rce�� Date: ; FOR DEPARTMENT USE ONLY Application Accepted by Area i ❑ Stk 466-6781 Additional Comments: IIL _ 4 — Lodi . 369-3621 Pit or Grout Inspection byli Date t Manteca 823-7104 Final Inspection by Date �t ❑ Tracy 835-6385 Applicant - Return all copies to:'Ii En viro tal Health Permit/Services 1601 E. Hazelton Ave'., P.D. Box 2009, Stk_, CA 95201 , JEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. EH 13-24 REV. 10/82 I� - 10/82 SOO 14-26 J