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APPLICATION FOR PERMIT SAN JOAQJIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 456=6781 , DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete ir,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 aW Regulati ns of the San Joaquir' Local Health District. Job Address �3l a� �r 0� Sub ivisionNName f Owner's Name Address y�lal c-& Phone Contractor's Name d . License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL. ' ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ., SYSTEM REPAIR ❑ OTHER L G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1 AGRICULTURE WELL OTHER WELL f PITS/SUMPS INTENDED USE TYPE OF]WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottcm C] Manteca Dia. of WelllExcavation 1 ❑ Domestic/Private ❑ Gravel}Pack [� Tracy Dia. of Well Casing 17 Public [ Other ❑ Delta Type of Casing . LiIrrigation Approx. ❑ Eastern, -_ Specifications` ❑ Cathodic Protection Depth - ""y-Depth,.of Grout,Seal ❑Geophysical, _ Type of Grout ❑Other = `-.Surface Seal.,Installed by * " i" Repair work Done ❑ Type of Pump H.'P. State Work Done>> Well Destruction ❑ Well Diameter t Sealing Material (top 50') r '9 " a Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION L EPA[R/ADDITION= is (No septic tank or seepage pit- permitted if public sewer is ,� available within 200 feet.) _ Installation will serve: Residence i Commercial Other L� �y — P—PCC.) y Number of living units: _ Number of bedrooms .7 •* Lot size de Character of soil to a depth of 3 feet: �"7� C/A-1 Water table depth. roX- SEPTIC TANK ❑ Type/Mfg E►..� C Akrekapacity P ! ' a. a arte is ?� PKG. TREATMENT PLT. Type/Mfg Capacity /2&10 — Method of Disposal E SEWAGE SYSTEM Distance to nearest: Well f� Foundation r _ Property Liner. "_Q r DESTRUCTION QN LEACHING LINE No. & Length of lines p��r°`�( f�l�` Total length/size FILTER BED ❑ Distance to nearest: Wel'1 _ Foundation '� Property Line i�cf "� ► SEEPAGE PITS Depth s Size Number ;%& k SUMPS ❑ Distance to nearest: Well/ZfL Foundations Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have"prepared this application and that the work will be done.].n-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 compensation laws of California." Contractor's hiring or sub-cortractinq signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empl ersors subject to workman's compensation laws of California." The ap a est call it Wqed ctio Complete ing on reverse side. Signed Title: ; Date' =PARTMENT S ONLYApplication Accepted by Area Stk 466-6781 Additional Comments: /�� r ❑ Lodi 369-3621 Pit or Grout Inspection ty ''� Date e U Manteca 823-7104 Final Inspection by Date _��+ �^ L} Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.D. Bax 2009, Stk., CA 95201 d f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ' EH 13-24 RFV. 10/82 (� 10/82 560 14-26 '��1p Y k