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APPLICATION FOR PERMIT SAN JCAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZFLTON AVE., STCCKTON, CA PERMIT NO. 5$ Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1-YEAR FROM DATE.ISSUED t (Complete in Triplicate) CA 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 LocalHealth Dist ! ,i 7tw Job Address Subdivisi me Owner's Name Address 7f C4 ct Phone 5/7�— $/fes Contractor's Name se No. o? 7` Phone TYPE OF WELL/PUMP WORK: NEW WELL [ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _�� SEWER LINES DISPOSAL FLD. PROP. LINE .P4 FOUNDATION AGRICULTURE WELL -,4,2-j _ OTMEf+--WEl-L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Industrial U Open Bottom EJ Manteca Dia, of Well Excavation 0Y i Domestic/Private Gravel Pack [:]Tracy Dia. of Well Casing F ❑ Public Other ❑ Delta Type of Casing # U Irrigation Approx. J<Eastern Specifications AMDepth /2__ Cathodic Protection — .- ❑ Depth of Grout Seal Sa ❑Geophysical Type of Grout r ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 4 State Work Done s , Well Destruction L1 Well Diameter Sealing Material (top 50') _ cy1 Depth Filler Material (Below 50') . A } r TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION i U (No septic tank or seepage pit permitted if public sewer is i — , available within 200 feet.) Installation will serve: Residence Commercial Other. e Number of living units: I Number of;bedrooms i Lot size� F Character of soil to a depth of 3 feet: - + . .= c '! Water table depth -r��nf1 e. Capacity ' SEPTIC TANK � Type/Mfg p Y No. Compartments 0 PKG. TREATMENT PLT. ❑ Type/Mfg, ± # . Capacity Method of Disposal 0 SEWAGE SYSTEM Distance to nearest: -Well ,Foundation Property Line .; DESTRUCTION ❑ t 3 LEACHING LINE ❑ No.' & Length of lines" Total length/size FILTER BED ❑ Distance,to,nearest:. Well (Foundation Property Line SEEPAGE PITS Cj Depth Size Number ' ! SUMPS Distance to nearest: Well t {Foundation 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 ; ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Nome 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 worknan� 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 mus all fo all re red Complete drawin on reverse side. Signed X Title: S Date: DE TM E ONLY Applicatio ccepied by Area 0".c �>5,stk 466=6781 V - Lodi 369-3621 Additional Comments: ❑ k Pit or Grout Inspection by Date ' jJ Manteca 623-s 7104 Final Inspection by Date ? 12 ED Tracy 835=6385 t Applicant - Return all copies to: , Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO i S yg _ �v _ 1082 500 EH 13-24 REV. 10/82 14-26