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• - .. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT NO. d G Telephone (209) 466-6781 DATE ISSUED 17-1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mode to the San Joaquin Local Health District Jor 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. e�glulations of the San oaquin Loc l Health District. Job Address .a-!� ( S e ! Subdi ision Name g Contras Name ' — Address / Phone r_/Z Contractor's Name IJ License No. - Phone L� 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 —t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ' TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ' ❑Tracy Dia. of Well Casing ' ❑ Public ❑Other ❑Delta - Type of Casing ❑ Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of. Grout Seal ❑Geophysical Type of Grout ❑Other , Surface-Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material (top 50') ` Depth 7 Filler Material.(Below 50') - 0 TYPE OF SEPTIC WORK: NEW INSTALLATION r,2T ';REPAIR/ADDITION U (No septic tank or.seepage pit permitted if public sewer is r— available within 200 feet.) Installation will serve:. ResidenceCommercial _ Other ' Number of living units: �_ Number of bed ons 3 Lot size Q 4� a . Character of soil to a depth of 3 fe t: Water table depth i--&/ +"5/' SEPTIC TANK ❑ Type/Mfg �Y ` Capacity —.2 0 O No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well 5 Foundation It) Line 5� LEACHING LINE [❑ No. d Length of lines I7 - 'Total ?ngth/size U FILTER BED' ❑ Distance to nearest: Well .100' Foundation., , 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 applican st-c 17 for all required.inspections. Complete drawing on reverse side. /� :77 Signed X —�-i+� Title: Date: R RTMENT U6E ONLY - Application Accepted by Area ,� ❑ Stk 466-6781 Additional Comments: [ /✓ - ❑ Lodi 369-3621 Pit or Grout`Inspection by - - Date /` -- ❑ Manteca 823-7104 Final Inspection by rr ��, Date +21 —f�'/- E]u—z— Tracy 835-6385 Applicant - Return all copies.to: Envi ental:Health Permit/Bfrvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE . BASE AMOUNT. DUE 'AMOUNT REMITTED RECEIVED BY DATE PERMIT ;NO INFO EH 13-24 REV. 10/82 10/82 500 14-26