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F0 2i__1984 SAN JOAQUIN LOCAL HEALTH DISTRICT APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT N0, DATE ISSUED ?`-7 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 1R i -t7 • N -� Subdivision Name Owner's Name T67tLj Address t&,f &one Contractor's NameiIA![ rt e_) .�� License No. / 5 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ C ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom E94nteca Dia, of Well Excavation I _ Dia.- of -Well Casin Domestic/private Gravel Pack Tracy 9' ❑ Public . CJ Other ❑ Delta Type of Casing L Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal F—IGeophysical Type of Grout El Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer -is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg Distance to nearest: Well _ Water table depth _ Capacity No. Compartments _ Capacity Method of Disposal Foundation Property Line 0 LEACHING LINE LJ No. & Length of lines Total length/size ol_ FILTER BED Distance to nearest: Well Foundation Property Line 0 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 workman � 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 compens tion laws of California." The applica must call for al equired inspec ion . Complete drawing n ever a side. y�J Signed X Title: Date: p `7' Application Ac epted PR D MENT USE N y by Area 2 p � � ❑ Stk 466-678I Additional Comments: Pit or Grout Inspection by Final Inspection by� Applicant Return all copies to: Envi FEE BASE AMOUNT DUE INFO EH 13-24 REV. 10/82 " 14-26 ❑ Lodi 369-3621 ---� Date Manteca 823-7104' Date ❑ Tracy 835-6385 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 13 • tti o b FS �� ! -- � � - 10/82 500