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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. V-703 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUEDo2 3 �! (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—H-74f A/. T,y��,rrn,y �D� /.Ol��Subdivision Name Owner's Name -6 1(C ��(� P(��Address s�t�� Phone Contractor's Name WOE ?rte License No- Phone :3971 -- O TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION IJ 4 PUMP INSTALLATION [] SYSTEM REPAIR OTHER ,� I DISTANCE TO NEAREST: SEPTIC TANK L� SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION l AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE _ TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 17 Industrial U Opej Public Type Bottom Manteca Dia. of Well Excavation 1-1 Domestic/Private �7 Gravel Pack Tracy Dia. of Well Casing Irrigation ` J Other Delta T e of Casing V Approx. EJ Cathodic Protection Depth Specifications — ❑ Geophysical Depth of Grout Seal j]Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction LJ Well Diameter[[_ Sealing Material (top 501) _ Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial X Other available within 200 feet.) Number of living units: � Number of bedrooms � — Lot size E�S �rtY•`a�.e .s.p gl-Ji'7 _ Character of soil to a depth of 3 feet: SA /p y i .� �,/ ,.-44!a _ Water table depth SEPTIC TANK L? Type/.!fg P,Lp��, _ P QL� _ Capacity t y'o a � No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal �.. Distance to nearest: Well 2,",/_ Foundation 7-0' Property Line y,p LEACHING LINE U No: & Length of lines mode Total length/size FILTER BED Distance to nearest: Well .-_7 2,M-�- Foundation' Property Line /p SEEPAGE PITS Cj Depth } Size Number SUMPS J Distance.to nearest: Well Foundation Property Line DISPOSAL PONDS 1r f-1 r I hereay 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 k 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 f r all required i pections. Complete drawing on reverse side_ Signed Xi Title: _ Date: DEPARTMENT USE ONLY Application Accepted by _ Area /Z E3 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104. Final Inspection by Date /'Q��Z Tracy 835-6385 Applicant - Return all copies to: Environ ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEErBASE AMOUNT DUE AMOUNT REMITTED - RECEIVED BY DATE PERMIT N0. INFO �� - s I EH 13-24 REV. 10/82 14-26 10/82 500