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APPLICATION FOR PERiMiT E SA.N JORQ iN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 -7 DATE ISSUED �7 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 n Joaquin Local Health District. Job Address �J4r� .. Subdivision Name Owner's Name Address Phone Contractor's Name ' License No. �Z Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE E FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS C/) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack ❑ Tracy Ria. of Well Casing Public [j Other Delta Type of Casing Li Irrigation Approx. Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal`Iristalled by Repair Work'Done Type of Pump H.P. State Work.,Don'e l' . Well Destruction ❑ Well Diameter Seating Material (top 50') � Depth '...--` -- -T � _.---- -- � _ ---• Filler Material' (Below 50') TYPE OF SEPTIC WORK: �`'�r1W/INSTALLATI6N__ PAIR., T (Nn septic tk- anor-seep`age-pa.t-permi-tted-i•f-public sewer is * �- Y ---- available-within 200 feet.) i Installation will serve: Residence Gommercia'W , �Other Number of living units:.,L Number of'bedroom Lot size 615F_ J Character of pil to a depth of, 3 feet: Ar i i�i��;�� f_ Water.table depth SEPTIC TANK F-1 Type/Mfg Capacity, No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity., Method ofrDisposal SEWAGE SYSTEM ""Distance to nearest: Well Foundation Property Line ' DESTRUCTION LEACHING LINE U No. & Length of 11nes '""`"�'"" - Total 11ength/size i FILTER BED D'i'stance to nearest: Well Foundation Property Line SEEPAGE PITS Cj' DepthSize X/ -Numb er—�—A- ----�- - �, SUMPS Distance to nearest: Well b0 Foundation Property Line S - DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed.agent's signature-'certi-fies-the following: "I certify that--in-the`performance-of-the-work for which this 4 permit is issued, I shall not employ any person in such manner as to become subject to workmanis compensation laws of California." i 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 m st call for all equired inspections. Complete drawing on reverse side. Signed X i h�,t�;� _ F Al— -- Title: Date: 2-/� _ fi.r F R DEPARTMENT USE NLY Application Accepted by. Area %} - [] Stk 466-6781 Additional Comments: � %�' Lodi 369-3621 Pit or Grout Inspection by, Date Manteca 823-7104 Final Inspection byDate ?I ( } Tracy 835-6385 Applicant - Return all copies to:, Environmental Hfalth Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, 5t k., CR 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO If 45 NO EH 13-24 REV. 10/82 10/82 500 14-26