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APPLICATION FOR PERMIT s SAN JOAQbiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, Telephone (209) 466-6781 / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED `t (Complete in Triplicate) 1 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 3 C/ :7a S'a, Pc�>1r /oy Subdivision Name Owner's Name A.7 /GY �„�� Address ^F. O6 Phone Contractor's Name ,y'fja,v V S- v License No. f/ — f/ Phone TYPE OF WELL/PUMP WORK: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS [� INTENDED USEEj TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pU Industrial - ❑ Open Bottom Manteca � ❑ Dia, of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia, of Well Casing �] Public �jOther Delta Lj Irrigation Type of Casing Approx. E] Eastern � ❑Cathodic Protection Depth Specifications { Geophysical ` Depth of Grout Seal LJ Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well DestructionDe U Well iam_ter - Sealing Material (top 501) Depth , i Fi11erAMaterial (Belo 50,) "TYPE OF SEPTIC WORK: NEW INSTALLATION ) REPAIR/ADDITION' see p'seepage(No septic tank or it ' U p g permitted if public sewer is �J�! ^ available within 200 feet.) ! Installation will serve: Residence i' Commercial Dther err - Number of living units: ! Number of bedrooms CIO" siie \+c,Cz��ycs Character of soil to a depth of 3 feet: Water table depth /00 SEPTIC TANK Vj Type/Mfg C&,vc. Capacity / o v": No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal a SEWAGE SYSTEM DESTRUCTION Distance to nearest: Well ori ' Foundation /5-1 Property Line /d0' ❑ LEACHING LINE U No. & Length of lines 3 49'0 Total length/size FILTER BED Distance to nearest: Well - Foundation 90 ` Property Line /470" SEEPAGE PITS ❑ Depth Size Number SUMPS ❑I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS e 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 becomesubject to vTorkman compen's`at-ion"Paws 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 musy call for all required inspections. Complete drawing on reverse side. Signed X Title: ®L � Date: .Z -! - PY /X 111 FOR PARTMENT USE ONLY :Application Accepted by /X111 Area 077 5tk 466-6781 p Additional Comments: ❑ Lodi 369-3621 I Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by &&VrDate L Tracy 835-6385 j Applicant - Return all copies to: . Environ-9vHealth Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 t FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ,, EH 13-24 REV. 10/82 I0182 500 " 14-26