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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED 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 and the Rules and Regulations of the San Joaquin Local Health District. Job Address Aslcc RoAD M-VA Subdivision Name Owner's Name R6w IPA-1 Address Phone Contractor's Name =16 CAP,(,,LC License No. 243r)'r Phone $23 65�y TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER EJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' N-3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial E]Open Bottom F-I Manteca Dia. of Well Excavation Domestic/Private ` ❑Gravel Pack ❑ Tracy Dia. of Well Casing Public F-1 Other*-, ❑ Delta Type of Casing F-1 Irrigation Approx. [] Eastern De th Specifications Cathodic Protection p ]Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done D Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) 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 within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms _ 4 Lot size _ 4© (W5 Character of soil to a depth of 3 feet: O Water table depth SEPTIC TANK Type/Mfg P(Zee-15r UO Capacity C0 No. Compartments PKG. TREATMENT PLT. (] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line y, DESTRUCTION Q - LEACHING LINE io No. & Length of lines _ Cr Total length/size V °/. FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have"prepafed'this- a-pplica:tibn-arid 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 workmant compensation laws of California." Contractor's hiring or sub-contract'ng signature-certifies the following: "I certify that in the�performance,of the work for which this permit is issued, I shall emp y persons subject to workman's compensation laws of California." The applica- call f all re ired inspections. Complete d��r'�aaqwi��n��g on reverse side. �-< Signed X �(�yi�.Fg - - - - - " -`Title: D.A)" Date: . I FOR DEPARTMENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: _ �`�� —E]—Lodi369=3621 - Pit or Grout Inspection by R Date Manteca 823-7104 Final Inspection by I�Shyo Date ..a —57 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 -- FEE—--BASE——AMOUNT—DUE AMOUNT-'REMITTED-- RECEIVED-BY— x"-"'DATE` ""'"' PERMIT N0-"` INFO EH 13-24 - REV. 10/82 10/82 500 14-2b