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APPLICATION FOR.PERMIT €I SA.N JOAQU,N LOCAL HFA.LTH DISTRICT 1601 E. HA7ELTO9 AVL., STOCKTON, CA PERMIT N0. �3 T>i1�1 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) F 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 I and the,Rules and Regulations of the San Joaquin Local Health District. l tJ1 Job Address S/ s �� Suhdivision Name ,. �a� lJ�Bz Owner's Name Address Phone Contractor's Name �-C7 License No. 2 �Z Phone TYPE OF WELL/PUMP WORK; NEL! WELL ❑ � WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER �.... T DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ 0pen Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ GraveI Pack. ❑ Tracy Dia, of Well Casing Public ❑ Other ❑ Delta Type of Casing [`1 Irrigation Approx. ❑ Eastern r Specifications Depth „_ ! vY Cathodic Protection p � - _ Geophysical Depth of Grout Seal LJ Other k Type of Grout ! Surface Seal Installed bye 3 Repair Work Done Type of Pump H.P. State Work Done # Well Destruction ❑ Well Diameter Sealing Material '(top 50' t Y f Depth Filler Material1 (Below 50') !f TYPE OF SEPTIC WORK: NEW INSTALLATION L�/I REPAIR/ADDITION U (No aseptic tank or seepage pit permitted if public sewer is Installation will serve: Residence l / *� Q available within 200 feet.) llk ��-r'Commercial Other Number of living units: Number of be ooms- --Lot size Character of soil to depth of feet: I �4w " Water table depth �� A r� SEPTIC TANK [ Type/Mfg ]U �r Capacity 'Z 100 No. Compartments PKG. TREATMENT PLT. Type%Mfg ! t Capacity Method of Disposal SEWAGE SYSTEM �— Distance to nearest: Well —F- Fo-undation Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines ,�'`` C7 Total length/size FILTER BED Distance to nearest: Well oundation Property Line SEEPAGE PITS LrjlDepthr size _�3 �! Number SUMPS L� Distance to nearest: Well Foundation k/1101--- Property Line DISPOSAL PONDS ❑ �-?"` I hereby certify that I have prepdiPed`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. '�'F` 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, cdmpensation 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 iss ed, I shall employ persons subject to workman's compensation laws of California." The applicant all for all reO fired inspections. Complete drawing o�n everse side. ' Signed X Title: Dater FO EPARTMENT USE ONLY ] = k Application Accepted by Area 01 Stk 466-6781 Additional Comments- Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection byDate L7 Tracy 835-6385 Applicant -- Return all copi Envi onmental Health Permit/Services 1601 E, Hizelton Ave., P.O. Box 2009, Stk., CA 95201 - T- .FEE-.. - BASE..« AMOUNT-1 DUE --AMOUNT REMITTED RECEIVED..BY ., DATE PERMIT NO. INFO - __ .. S o0 1 AV7 11 I ; EH 13-24 REV. 10/82 } 10/82 500. 14-25