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APPLICATION FOR PERMIT SAN JOAQU'iN LOCAL HEALTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 -A. " � DATE ISSUED S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED." (Complete in Triplicate) r 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 o q L. .,�• �} ;ItoW Subdivision Name �-x►�- Owner's Name F%dcf 4dS Address 11-9 '4L—. W,\Ip„_, 4v4 Phone 030 Contractor's NameOwN`License No, �n:lrtS�. Phone . rr TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSR INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fJ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta TypeIrrigation p Approx. ❑ Eastern Spec of Casing Depth Specifications ❑ Cathodic Protection p Depth of Grout Seal ❑Geophysical r F-1 Other Type of Grout li 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 REPAIR/ADDITION No septic tank or seepage 1 LJ ( pit permitted if public sewer is I t1 available within 200 feet.) fl-i Installation will serve Residence Commercial Other Number of living units: L Number of bedrooms , Lot size 1 SX�U Character of soil to a depth of 3 feet: Sc,A-111 - — Water table depth SEPTIC TANK 2r Type/Mfg " P4-L- i!;!S e4 Capacity !-Z-O O No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal 61dSEWAGE SYSTFM Distance to nearest: Well Foundation Property Line _.� DESTRUCTION �hf�" If LEACHING LINE No. & Length of lines Total length/size- FILTER ength/size FILTER BED Distance to nearest: Well Foundation f ❑ � /Q� Property Line SEEPAGE PITS ❑ Depth, size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ;, 10m, _i�A is 'ay-44• hot h Le uft� as_dt,vtwriy pr 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. ` Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which t$lis permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." d 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 compensation laws of California." IiI The applicant must call for all r pections. Complete drawing on reverse side. J Signed K 1 9 � Title: � Date: � DEPAR MENT USE ONLY a Application Accepted by R Area _ ❑ Stk 466-6781 74 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date 10,7 \-].-Manteca 823-7104 Final Inspection by' ��J] �14�__ Dates 3 ❑ Tracy 835-6385 Applicant - Return all copies to: Vvironmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATgE� PERMIT/ NO, INFO T EH 13-24 REV. 10/82 �}QL A_ �� 10/82 500 14-26 - , ff✓ �PJI'A1�