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r APPLICATION FOR PERMIT arf � 19841SAN JOAQUiN` LOCAL HEALTH DISTRICT k ill 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3_'7(24 SAN JOAQ13til1 LOCAL. Telephone (209) 466-6781 DATE ISSUED'A-« ajM-M DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) u, Application is hereby made to the San Joaquin Local Health District fora permit to Construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San.Joaquin Local Health District, r' !� s /S W. Subdivision Name Job Address Q.S owner's Name Address Phone Contractor's NameY ��.'r!� Phone TYPE OF WELL/PUMP WORK: NEW WELL [--IWELLREPLACEMENT- DESTRUCTION i PUMP INSTALLATION ❑ SYSTEM REPAIR U. OTHER LJ /l U DISTANCE TO NEAREST: SEPTIC TANK �� DISPOSAL FLO. PROP. LINE�� SEWER LINES �...- 6 FOUNDATION AGRICULTURE WELL OTHER WELL %QL PITS/Sl1MPS: , INTENDED USE n TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� IIndustrial U Open Bottom [] Manteca Dia. of Well Excavation i domestic/Private y Gravel Pack Porlacy Dia. of Well Casing r 17 Public F-1 Other ❑ Delta Type of Ging P 71 Irrigation Approx. []Eastern Specifications ❑ Depth Cathodic Protection Depth of Grout Seal / 17 Geo hysical Type of Grout - ther C47- n& Surface Seal Installed by State Work Dome Repair Work Done D Type of Pump Well Destruction U Well. Diameter Sealing Material (tap 50') C Depth Filler�Material (Below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION L1 REPAIR/ADDITION J -(N6_-septic tank or seepage pit permitted if public sewer is . . .ti :y� available within 200 feet.) Installation will .serve: Residence _ Commercial _ Other " .- , Number of bedrooms a``= Lot size Number 6f liv"irtg--units:. Characte r.of soil to 4 depth of 3 feet; Water table depth SEPTIC,TANK J ` lType/4g Capacity No. Compartments �I Capacity Method of Disposal PKG, TREATMENT PLT. F Type/Mfg `SEWAGE SYSTEM "� Distance to nearest: Well Foundation - Proper-ty"Line _ - - �.»•��++ DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size k FILTER BED Distance to nearest: Well Foundation Property Line ❑ �° w SEEPAGE PITS El '� Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line 4k, DISPOSAL PONDS �I t 1 hereby certify1that 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 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant st for a 1 required inspections. Complete drawing an reverse side. Signed X Title: f'y)7 fJ/1 Date: w F DEPARTMENT USE ONLY Area Stk. 466-6781 Application Accepted by _ CA. — ---- Additional Comments: [� Lodi 369-3b2i r Pit or Grout Inspection by Date - Manteca 823-7104 + iI Tracy 835-6385 Final Inspection -by, Date Applicant - Return all c6pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, St k., CA 95201 r =� B AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �� b� � �,..�_ i.•� i 10/82 500 EH 13-24 REV. 10/82 14-26