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• APPLICATION FOR PERMIT SAN JOAQhiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ES S Ji Z� 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 yQ u.,<5;:T F/�Ci >re'� Subdivision Name Owner's Name Address Phone Contractor's Name e�� /=�/��[�'yJ� License No. Phone ?r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 1-1 Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation _ ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing _ ❑ Public ❑Other ❑ Delta irrigation Type of Casing L—i 9 Approx. ❑Eastern Specifications ❑Cathodic Protection Depth ❑ Depth of Grout Seal Geophysical ❑Other Type of Grout G Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 (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: �_ Number of bedrooms �_ Lot size �Gi! --- o2O Character of soil to a depth of 3 feet: /L Water table depth SEPTIC TANK ] Type/Mfg Capacity 14 No. Compartments ra, NI FLI. U 1y;":,'"'` i — --- ---- Capacity _ Method of Disposal SEWAGE SYSTEM _JFT r P Distance to nearest: Well Foundation F Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines D Total length/size M x FILTER BED Distance to nearest: Well %<ff Foundation A V F� Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 workmank 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 c.011 for 11 re u'red inspections. Complete drawing on reverse side. Signed X Title: _994"!m Date: FORRTMENT USE ONLY Application Accepted by /1_(,�,�, Area _1 ❑ Stk 466-6781 Additional Comments: ❑ Lodi : 369-3621 Pit or Grout Inspection Date -5;Z-Manteca 823-7104 Final Inspection by I NFA_AA1 Date � L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services I& E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO L-A cz EH 13-24 REV. 10/82 10/82 500 14-26