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.APPLICATION,FOR PERMIT . t SAN JOAQUiN LOCAL HEALTH C.DISTRICT 1601 E. HAZELTON AVE.,'STOCKTON, CA PERMIT NO. Z a Telephone (209)'466=6781 - DATE ISSUED (P- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (Complete in Triplicate) " ', x: Application is hereby made to the San'Joaquin Cocal 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 Joagdin'Local Health,,0istrict. ` Subdivision Name .r) iJob Address Owner's Name r Address . Phone -b, 11 Contractor's Name Q LicenseNo. 12r -2-7 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO_NEAREST: SEPTIC TANK A SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS I Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing' ,w ❑ Public.. ❑ Other ❑ Delta Type of Casing Irrigation Approx. E]-Eastern Specifications •r h❑Cathodic Protection Dept # k, Depth of Grout Seal ❑ Geophysical 01, to Type of Grout r+ €❑Other t# , Surface Seal'Installed by Repair Work Done '-Ty.e of Pump h HSPf f i State Work Done 16 4 Wel.1 Destruction ❑Well Diameter;.L ,.rSeal'ing Material (top 50') NO * DepthIK C-10 Filler Material (Below 50') TYPE OF'SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITIONf_,F7r,(No'septic- tank or seepage pit permitted if public sewer is r a1 t •../ available within 200 feet.) Installation will serve.: Residence _ Commercial Other Number of bedrooms �'>t-- Lot size .� G� �' � #� Number of living units: _ p- -� t � Character of soil to a depth of 3 feet: ��y Water table depth p �i 'f " SEPTIC TANK ❑ Type/ Capacity No. Compartments i �' PKG. TREATMENT PLT. ❑ Typ� _, F Capacity Method of Disposal a� SEWAGE SYSTEMDistance to nearest:r Well :S�ig Foundation 1;7s , Property Line, �� DESTRUCTION I i LEACHING LINE No. & Length of lines 1 Total length/size X 2 j J FILTER BED Distance to nearest: Well _S'47 Foundation Property Line T _ dott rY SEEPAGE PITS --Depth ., ) Size t t Numb$r SUMPS Distance to nearest: Well I t2 Q._ Foundation' P roper tyline � DISPOSAL PONDS Cly r i I hereby certify than] have prepared4this 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 licensee 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 workmant compensation laws of California." Contractor's hiring ar'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 for all re aired i specticns. omplete drr ing on reverse side. Signed X Title: ` •/ Date: FOR DEP ENT USE ONLY !� " —"1 -Pplidation'Accepted by--"`C``i;L a,•- V - ❑ Stk 466-6781 Additional Comments: q Lodi 369-3621 Date ❑ Manteca 823-7104 Pit or Grout Inspection by f k � Final Inspection by Date Tracy 835-6385 Applicant - Return all copies 0: 1 Environ ental Health Permit/Services 16.1 E- azelton Ave., P.O. Box 2009, Stk., CA 95201 nFEEBASE AMOUNT, DUE AMOUNT REMITTED RECCEIVED BY DATE �PERIINO�!v DS - EH -13-24 REV. 10/82 - 10/82 500 14-26