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t ( APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. �J 63 Telephone (209)466-6781 . PERMIT EXPIRES 1- YEAR FROM DATE [SSUEC DATE ISSUEDIA —3 (Complete,in Triplicate) Application is hereby made'fto 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. f ti�1 Job Address ca23 �, S. 410.2 Ca Ad Subdivision Name Owner's Name A Ar k ,p!` 1 el h Address J /.6 .1 F it C Ad Phone �a3- �/31?y Contractor's Name ,r1t License No,. Phone _S9Q— 3 �3� TYPE OF WELL/PUMP-WORK: ° NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USEd TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel PackTrac ❑ Y Dia. of Well Casing ❑ Public f ❑ Other ❑ Delta Lj Irrigation f Type of Casing Approx." Eastern - ❑ CathodiclProtection Depth Specifications ❑ Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth --,.,.,,`,Filler Material (Below 50') ' I h TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ) i Installation will serve: Residence _ Commercial w Other available within 200 feet. � Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity ,, Method of Disposal SEWAGE SYSTEM Distance to nearestWell L �Foundation Sot—,DESTRUCTION � ��perty r Line LEACHING LINE J No. & Length of lines Total length/size I FILTER BED 1, ❑ Distance to nearest: Well 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 ac ordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health.District. I Home owner or licensed agent's signature certifies the following: "I certify thattin 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 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 mu call for all requ' ed inspe tions. Complete drawing on reverse side., if7 Signed x e Title: �CC)14 ��Q C�'iQlr' ,+- Date: l D RTMEN7 USE ONLY +< —�] 'I Application Accepted by Area. �` Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date "F Manteca 823-7104 r Final Inspection by Date � � �p3ti ❑ Tracy 835-6365 � Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0 ox 2009, Stk., CR 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 i ,q p� 1 10/82 500 14-26