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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DI"STRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. M--)- Telephone (209) 466-6781 DATE" ISSUED- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Local Health District. ` Job Address . Subdivision Name ^- Owner's Name "T Address Phone "v fo�7 I� Contractor's Name License No. Phone k TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 ❑Open Bottom []Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing Public k ❑ Other El Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications Depth❑ Cathodic Protection Depth of Grout Seal- Geophysical _ -Type of Grout ❑Other Surface Seal installed by + Repair Work DoneType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter ;Sealing Material (top 50') `b Depth Filler Material (Below 50') 1 5 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other Number of living units: Numberof bedrooms Lot size /40KO +c 12 Ti J t Character of soil to a depth of 3 feet: S Water table depth _-4S:Z) SEPTIC TANK " 0' Type/Mfg 0:5INC, F/E} 1$, Capacity t2Z-,y1e2 _ No. Compartments 2- PKG. PKG. TREATMENT'PLT. [] Type/Mfg ` 3 Capacity Method of Disposal Distance to nearest: Well Foundation �� •� Property Line -07, ,LEACHING .LINE ®' No. & Length of lines /30 lye' _ Total length/size 70K �s1i FILTER BED ❑ Distance to nearest: Well A--*,/pa. Foundations Property Line �� SEEPAGE PITS Depth .2t4;_ Number_ ' Size 3G, __ SUMPS ❑ Distance to-nearest: Well /} Foundation ' Property Line �S DISPOSAL PONDS ❑ 14 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 3 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner-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 hi ing or sub-contracting - nature certifies"the following: "I certify that in the performance of the work for which this permit i sued, I shall employ rsons subject to workman's compensation laws of California." The applic call fo all re red inspections. Comple dr on reverse side. Signed ` Title: Date./IL J �61Z'I A ENT USE ONLY �. . Application Accepted b 'Area ' Stk 466-6781 Additional Comments: kZr Tb §r= LU l9 Al 0iM0 70E ] Lodi 369-3621 Pit or Grout Inspection by Date /7V-7-A-2-- ❑ Manteca 823-7104 i Final Inspection by , r Date 0 Tracy 835-6385 �� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. ,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO R45 • � 8 vv C ev7e EH 13-24 REV. 10/82 10/82 500 14-26