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71� APPLICATION FOR PERmi_ ' SAN JCAQUiN LOCAL. HEALTH DIST 1601 E. HAZLLTON AVE., STOCKTON, CA JUN 3 01983 PERMIT NO. Telephone {209)466--6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE 1s5M JO Q3 141 LOCAL (Complete in Triplicate) HEALTH DISTRICT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/crinstall 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 Re ulations of the San Joaquin Local Health District, � � ] Subdivision Name Job Address _ Owner's Name L.E(r! dress �. s hone �•r 2i Contractor's Name ! License No. 6 .2-7 7 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ��}r�' OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL '- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Vv 'Dia.=of-t3e11�ExcavatiTinT �Industri-alp--=-�.^- �-""`U-Opeh-Bottom��-�-❑�lantee a�"'� Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of'Well Casing` 1 Public Other Delta F f ❑ ❑ ❑ Type of Casing Irrigation Approx. Eastern Specifications ( ❑ Cathodic Protection Depth t Depth of Grout Seal ❑ Geophysical Type of Grout Other LJ / Surface Seal Installed by Repair Work Done [?r Type Type of Pump ,JH•L P. [ State Work bone Well Destruct'on ❑ Well Diameter Sealing Maferial (top 50') — ,t p 3 �1I o Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION❑ 'REPA,IR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) lnstallation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Il Character of soil to a depth of 3 feet: _ Water table depth E SEPTIC TANK U Type/Mfg .p Capacity No, Compartments PKG. TREATMENT PLTYI❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 'k DESTRUCTION U 1 LEACHING LINE ❑ No. & Length of lines + Total length%size. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑'.. Depth Size Number. SUMPS Distance to nearest: Well Foundation Property Line v ��OI"SP05AL",PONDS--� "❑}��.__�_,_:�.� _�. __._._:..-.� . ..�._..�..,,; , I hereby certify that I have prepared this appl"ication and;that'the work will be done in accordance with San Joaquin county ordinances,lsta.te laws, and rules and regulations of the San ]6agyir Local Health District. Home owner or licensed agent's signature certifies the following:'I'll certify that in the performance of the work for which this y permit is issued, I shall not employ any person in such manner as to become subject to workmanL 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.,...1 shall employ persons subject-to.workman'$.compensation laws of California." The applican st all�fo equired inspections. Comple drawing on reverse side. 4 Date: signed X tle: I FOR DEPARTMENT USE ONLYr ` Application Accepted by Area Std 0.65-6781 Lodi 369-3621 Additional Comments: ❑ d Pit or Grout Inspection by r%Date - --� ❑ Manteca 823-7104 Final Inspection by 1 Date /a 1� �� L Tracy 835-6385 Applicant - Return all copies to: EnvironPermit/Sery mental Health ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 RECEIVED BY DATE PERMIT NO. FFEE .� BASE AMOUNT DUE AMOUNT REMITTED 10/82 500 EH 13-24 REV. 10/82 14-26 L