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APPLICATION FOR PERA;IT V SAN JO AQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3- Telephone (209) 466-6781 DATE ISSUED _7 L27 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) ' Application is-hereby made to the San Joaquin Local Health District for a permit to'construct arH/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 f�,7jj G'��(J/� LC xo, Subdivision Name Owner's Name W 14"y �$,��Ly-Cl/y! Address _ _; 54f/>jF Phone 9�/rip/Cj Contractor's Name ate,¢/s�� License No.; Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT. DESTRUCTION L PUMP INSTALLATION ❑ SYSTEM REPAIR L COTHER' L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESi DISPOSAL FLD` PROP. LINE FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS r� # ? - v" F INTENDED USE TYPE OF WELL PROBLEM AREA n CONSTRUCTION SPECIFICATIONS l VL Industrial L Open Bottom ❑Manteca Dia, 6f Well Excavation L Domestic/Private Gravel Pack Tracy �" ' Dia. of Well CS-sing . F Public Other Delta 1 Type of Casing � L.Irrigation Approx. Eastern —I Depth Specifications .. -Catho"di"e`Protection Depth of Grout Seal 17 Geophysical Type of Grout L Other Surface Seal Installed by 'Repair Work Done FJ Type of Pump H.* State Work Done Well Destruction L Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg 11 1 p i Sft2%/2 Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest. Well Foundation Property Line. DESTRUCTION LEACHING LINE L No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth .23"/ Size f j� �z Number _ SUMPS Distance to nearest: Well /5-0 Foundation /D r Property Line 1Qr DISPOSAL PONDS ED 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 compensation laws of California." The applica ust call for All re ui d s ect'ons. Complete drawing on reverse side. Signed X Title: Date: g3 FOR DEP Application Accepted b �2 _,____ 1 Stk 466-b7 Additional Commen Sg:;5Kea 01 Lodi 369-3621 Pit or Grout Inspection by Date ay�f� ❑ Manteca 823-7104 Final Inspection by - Date L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16CI E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 rIN BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. EH 13-24 RFV. 10/82 (Y,, 10182 500 14-26