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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. "`� ';a a ' Telephone (209) 466-6781 ( DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED ¢ f (Complete in Triplicate) E i 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 fell/pump /, and the Rules and Regulations of the San Joaquin Local Health District. r �_ , �. ,� Jab AddressZV- 3 p��G.rQD. Subdivision Nam/e�,� u ► Owner's Name B i �{} Address,gj.9�47F m7oT ,r CQ-a Q�diD'�S TPhon e429 9''30d]7 G Contractor's Name g License No. Phone " (a,-9(Q,!R TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT E] DESTRUCTION U PUMP [NSTALLATION ;� SYSTEM REPAIREl OTHER—L—j a "I5 r" t ` z y w D. STANCE TO NEAREST: SEPTbC TANK �'� `tic {SEWER L`tN � l �- t JDI:�SPOSAL=FLR..r. PROP, LINE s FOUNDATION $AGRICULTU RE WELL ' 5 OTHER ELL,. y PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS Industrial I U Open,Bottom E] Manteca"' _Dia. of Well Excavation W U Domestic/Private Gravel Pack e ❑Tracy Dia. of Well Casing Public Other 4 Delta Type of Casing : Lilrrigation Approx. Eastern Oe th ' Specifications f Cathodic Protection p Depth of Grout Seal j T Geophysical 4 Type of Grout U Other Surface'Seal Installed,by` c Repair Work Done ❑ Type of Pump J H.P. State Work�Done x Well Destruction U Well Diameter i Sealing Material (top 50') Depth ! Filler Material (Below 50') y 4 3 TYPE OFiSEPTIC WORK: NEW INSTALLATION U ' REPAIR/ADDITION '�r (No septic tank or seepage piC permitted if public sewer is ii :: available within 200 feet,) I v L Installation will serve: Residence _ ' Commercial X_ Other i s Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: 4119 1 Water table depth SEPTIC TANK t Type/Mfg c Capacity . No. Compartments ) PKG. TREATMENT PLT. Type/Mfg Capacity' Method of Disposal ` SEWAGE SYSTEM Distance to nearest: WelI Foundation" Property Line f DESTRUCTION ' ❑ i f t "' v'�r Total length/size LEACHING LINE No. & Length of lines 5 '. FILTER BED 3 Distance to nearest: Well Foundation 6447 Property'Line /d - SEEPAGE PITS ' Depth : Size L�- i +� J". Numbier,, SUMPS A L� Distance to nearest: Well Foundafon`^ /8� Property°Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county f i ordinances, .state laws, and rules and regulations of the San Joaquin Local Health District'.. i 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-contracting signature certifies the following: I certify that in�the performance'.of the work for which this permit is 'slued, I;shall employ pe sons subject to workman's compensation laws of California." The applican tt ea _ r all quiz inspections. Complete drawing on reverse side, r Fr,. > rd.=. Signed X Title: Ys�, Date �•,Z,J'Zi; c � AR ti?ARTMEN USF ONLY � .: +' 6', ? Application Accepted by" ' ,r ' "Area _ ] S,Lic466 6781 Additional Comments: s" ;' ! ".^r' {7 ❑ Lodi 3693621 1 4, Y'tti r n Pit or Grout Inspection by % t -.Date_ ; +Mantec823 7b04 Final Inspection by Date Tr-_acy ;835 63$5 'A; Applicant - Return all copies En�ronmental Health Permit/5ervice 1601 E. Hazelton Ave;, P.O. 8oxr2009; St CR 95201 ' F rE£ — SE�'""�"'""AMOUNT—'DUE— "-AMOUNT-REMITTED �--� - -REEEI-VED-BY— 7A•TE ' ��,_PERI�I.T:N0. , B7A r) � �. E;�'P. *,._s 1��? �.R }.er,.�5�•,.;i`� .�'rte. � r '� ..�' 10/82 500 EH 13-24. _ REV. 10/82 l: