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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT ND. (�-� 7.33 Telephone (209) 466-6781 DATE ISSUED a?/ -2— PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the An Joaquin Local Health District for a permit to construct and/or install the workherein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump - j and the Rules and Regulations of the San Joaquin Loca-1 Health District. Job Address_ f7 X. -V7,r�• Subdivision Name Owner's Name 1 /y s GGE Phone 741 _s 8Z Contractor's Name ;3� License No. Phone a3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l�J ,: DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION ib AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE, TYPE`4-WELL+•TPROBIEM'AREA��CO_NSTRUCTION SPECIFICATIONS 17 Industrials ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T Domestic/Private ' ❑Gravel Pack ❑ Tracy Dia. of Well Casing 1 Public� ❑Other ❑ Delta i Irrigation I I Type of Casing 9 Approx. ❑ Eastern,I Specifications Cathodic Protection Depth ❑ Depth of Grout Seal Geophysical Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction ❑ Well Diameterl Sealing Materiah&'(t p 501.) Depth Filler Materi t1(Belaw 509 TYPE OF 5EP7IC WOR : NEW INSTALLATION REPAIR/ADDI1'IOA N 4 p seepage p p public sewer is U (No}se tic tank or see a e it permitted if i 1tb,A4�t,-available;within 200 feet.) Installation w li Lrve: Residence Commercial ,rOther z Number of living'uh-t s: _ dumber of bedrooms Lot size d'�s p 47 Character of soil !to:-ay depth df 3 feet•• »F Water table depth -- -� SEPTIC TANK Type/Mfg u Capacity 12-400 No. Compartments '� PKG. TREATMENT PLT:. ❑ Type/Mfg Capacity Method of Disposal Septic Tank i P Distance �o nearest: Well* . 1%J .1IfJ Pr�perty Line _ �® Destruction �-� LEACHING LINE1�;No. & Length of lines Pv, Total length/sive FILTER BED r'sXETr❑" Distance to nearest: Well - Foundation Property Line SEEPAGE PITS [] Depth Size r --J Number F SUMPS Distance to nearest: Well Foundation Prbperty Line f DISPOSAL PONDS ❑ n I hereby.certify that I have prepared this application and that the work will be done inraCcordance 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, JI' shall not employ any person in such manner as to ;become subject to workman compensation laws of California." Contractor's hiring or:sub=con tract ing signature-certifies1the-f611owing: "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 mus call f r alllreq ir�ed ii ctions.: Complete drawing on reverse side. Signed X �r Iv-4 Ti le: Date: OR DEPARTMENT USE ONLY Application Accepted .by Area Q _ Stk 466-6781 Additional Comments: _CTl ❑ Lodi 369-3621 Pit or Grout Inspection by Date � ❑ Manteca 823-7104 Final Inspection by Date 2_ ❑ Tracy 835-6385 Applicant - Return all c i to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO " EH 13-24 REV. 10/82 10/82 500 14-26