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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HE4TH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NC. y(� Telephone (209) 466-6781 DATE ISSUE 1) .� O 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. Th' /,q�p on is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules ttl'RR ons of the San Joag4uin Local Health District. Job Address 430..,re��y Rt! Subdivision Name hO;%P' Owner's Name 1�n �S�lt v�wV�CP_ .i Address 7C(30 Vic-% ev—�.� �c� L�aae►J ens Phone 887 32-37 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ x PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ? DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^0 I Industrial '`Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack Tracy Gia. of We'.l Casing ❑ Public I Other ❑ Delta Type of Casing Irrigation Approx. ❑Eastern Depth Specifications Cathodic Protection Depth of Grout Seal 1 ❑Geophysical Type of Grout t' ❑Other Surface Seal Ins'.a'led by Repair Work Done ❑ Type of Pump N.P. _ State Work Done Well Destruction F_ Fell Diameter Sealing Material (top 50') Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTA�I�N1>1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is �+ available within 200 feet_) Installation will serve: Residence Commercial _ Other ,A Number of living units: I Number of bedreons _ — Lot size I- A-c C S f Character of soil to a depth of 3 feet: La ___Pq Onep PAI) Water table depth >200 SEPTIC TANK Type/Mfg Capacityy No. Comoartments PKG. TREATMENT PLT. U Type/Mfg r� Capacity V Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well 700 Foundation /0 Property Line /00``� DESTRUC-ION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: 'Fell Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work wil' be done in accordance with San Joaquin county i 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 per`ormance of the work far which this ; permit i$ 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 performiance of the for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applican must call f al required inspections. Complete drawing on reverse side, p �_ n Date:-altWhe. Signed X _ �JL Q �J�� Title: 'ar P RTMEN E ONLY Application Accepted Area 491-S ❑ Stk 466-6781 Additional Comments: _ LJ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection byDate g-2,0-f3 3 ( Tracy 835-6385 Applicant - Return all cops o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,G. Box 200q, Stk., CA 55201 FEEBASE -93 AMOUNT DUE AMOUNT REMITTED �RE/CEEIIVED BY DATE q PFRMII NO. INFO d U 3'� EH 13-24 REV. 1C/82 r 10/8% 500 14-26