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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 .E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) 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 :Heal' Di4Xict. Job Address a2 / 5'-11 -/t D 7 Subdivision Name - Owner's Name Z-A- S Address 3/A4. �- ,q,u7LPhone Contractor's Name , ,L1/ L _ License No. �4?` Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE u. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom F1 Manteca Dia, of Well Excavation V Domestic/Private E]Gravel Pack ❑Tracy Dia.-of Well Casing Pub Iic ]Other Delta J �, U IrrigationApprox. Eastern Type of Casing v1 � E]Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal �3 Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 'State Work Done ` Well Destruction ❑ Well Diameter Sealing Material (top 501) Q Depth ' Filler Material (Below 50')`„ TYPE OF SEPTIC WORK: .NEW INSTALLATION REPAIR/ADDITION L_I (No 'septic tank or seepage pit permitted if public sewer is R` (� Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of Iiving units: Number of bedrooms _L� Lot size Character of soil to a depth of 3 feet: 10-k� A ; M � �� - Water table depth SEPTIC TANK �I Type/Mfg Cap city;:�t _No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c Distance to nearest: Well .lam Foundation /p "4 Property Line DESTRUCTION LEACHING LINE Nod & Length of lines _ �— 70 Total length/size FILTER BED Distance to nearest:- Well /aye Foundation ?-. - Property Line SEEPAGE PITS ❑ Depth Size Number �' 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ED w� 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 workman t 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 workmari's compensation laws of California." The applicant must call r 1 re ui^ed inspections. Complete drawing on reverse side. Signed X r Title.-W Date: FOR DENT USE ONLY _ 1 Application Accepted 6y Area I = St k- 466-6781 r Additional Comments: - - Lodi 369-3621 •i Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by (�/D�� Date L' Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 00 'EH 13=24 REV. 10/82 g , 14-26 � 10/82 500