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I' APPLICATION FOR PERMIT Y� it SAN JOAQUINLOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA., PERMIT NO. Telephone (209) 466-6781 " i DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a" (Complete in Triplicate) Application is hereby made to theSanJoaquin 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 cal Health District. w Job AddressrJ� C,^ Subdivision Named � � _ . . Owner's Name Addre s _ Phone Contractor's Nam License No. Phone " TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION [] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK d! SEWER LINES DISPOSAL FLD. PROP. LINE r6 FOUNDATION AGRICULibRE WELL OTHER WELL PITS/SUMPS jL INTENDED USE TYPEIOF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open" Bottom ❑Manteca A Dia. of Well Excavation L ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Public T� ❑ ❑OtheIr ❑ Delta Irrigation �I Type of Casing U g Approx. ❑ Eastern ❑ Depth Specifications Cathodic ProtectionDepth of Grout Seal ❑Geophysical ❑6ther Type of Grout / J Surface Seal Installed by Repai r Ubrk"Oone'❑'_Ty"pe"of'Pump I1.P- _... -` r_� State Work hone�_._- ...� _. _�� Well;Destruction ❑ Well Diameters Sealing Material (top 50') # _ Depth Filler Material (Below 50') „ - TYPE OF SEPTIC WORK: NEW INSTALLArTION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is i! availablewithin 200 feet.) Installation will serve: Residence Commercial Other , �7 j Number ofl"1"i+iing units:`} ' "I'NUmber 6 -bedrooms Lot size Character,of soil to a_'-depth o#�`�3 jfeet: Q -.Y. Water table depth SEP111C TANKType/Mfg ' Y/,y+L Capac;�tyNo. Compartments PKG: TREATM!ENT PLT. [ '�l'•Type/Mfg'll c _ Capacity .�2 6&-O� .Method of Disposal SEWAGE SYSTEM �"i �� y.�.- "--Distance to nearest: Well Foundation's /07-Troperty Line �3 ` !DESTRUCTION ❑ i i.z.._... - ;LEACHING LIME_. No. 8 Length of lines _ 3frrd Total length/size Cl- J '- FILTER BED ? Distance to nearest; We1A' Foundation) Property Line y r " ` SEEPAGE PITS ❑ Depth '.F Size Number SUMPS I-1 Distance to nearest: We7.1 Foundation Property Line } t_,1�ISPOSAL PONDS ❑ �� f _ r(' I hereby certify that I have preparred 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. Horrid owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrrift is issued, I shall not employ any person in such manner as to become subject to workman� 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 a ubject�to,workmanls._compensation laws of California."' The;applicant must ca 1 f 1 rw g ed- inspections!. CompletevArawing on reverse side. Signed % �r + I "'T ._ ..' Title: . s ' I Date: $—1 ` FOR DEPARTMENT.USE_ONLY.,.,,,�,.._._._ f Application Accepted by II' Area ;�� m > ❑ Stk 466-6781 ' Additional Comments: .1� i I ❑ Lodi 369-3621 i , Pit or Grout Inspection by!C Date ; Manteca 823-7104 Final Inspection by Fracy�1 Date ; 835-6385 Appllicant - 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 p DATE PERMIT NO. INFO ' 70 3w EH 13-24 REV. 10/82 10/82 500 14-26 _.