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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT Lam` 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. es- Telephone p s- " ff Telephone (209) 466-6781 • DATE ISSUED S'-y �$S PERMIT EXPIRES 1 YEAR FROM 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 s and the Rules and Regulations of the San Joaquin Local Health District. Job AddressOT 9 W%LeA X RZ , Subdivision Name Owner's Name "'FOr^ 'T'L 12409Address { to, hone Contractor's Name 11f-"C4 YY1EclF. V44icense No. Phone 1 3 { —x,03 1 . TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTIONS] PUMP INSTALLATION SYSTEM REPAIR OTHER U u1' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7+ II 1 Industrial U Open Bottom Manteca Dia. of Well,Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia.. of Well Casing L-1 Public F-1 Other Delta Type of Casing D Irrigation Approx. Eastern Specifications =- Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout \J Other Surface Seal Installed by (` Repair Work Done F] Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available wit in 290 feet.) Installation will serve: Residence _ Commercial X Other 'S[24;L 16,— bVavo Number of living units: Number of bedrooms Lot size 5-3, '2,M '2! Ohl Character of soil to a depth of 3 feet: [' 1►Pt y Water table.depth { 0 0 SEPTIC TANK Type/Mfg Q ST N Capacity _Jkpo G+►lE No, Compartments PKG. TREATMENT PLT. Type/Mfg Capacity �__ _ Method of Disposal SEWAGE SYSTEM Distance to nearest: Well �7 Foundation n _ ._ Property Line {Q DESTRUCTION LEACHING LINE No. & Length of lines (� �L d �d _ Total length/size FILTER BED Distance to nearest: Well J 00' Foundation /O Property Line S r SEEPAGE PITS Depth —z� Size Number t'D SUMPS Distance to nearest: Well Foundation i 66 _ Property Line DISPOSAL PONDS C1 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, 1 shall not employ any person in such manner as to become subject to workmant 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 m st call for all required inspections. Complete drawing on reverse side, Signed XTitle: ➢ate: rf v FOR DEPARTMENT USE ONLY Application Accepted by Area U 2 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection DateWE. azelton Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: L�Ivi ental Health Permit/Services Ave_ P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIGT NO. INFO SOD 5-- -�5 85- t !! 10/82 500 EH 13-24 REV.' 10/82 14-26