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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. r- Teiephone.(209) 466-6781 L93 PERMIT DATE ISSUED J 1� 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) P MMUA) I°C�T(dtiS 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 Aistrict. Job Address _ S`rlir �� /Y17�*f/JE�T d :g-�• _Subdivision Nameal Owner's Name A fpi4m r�xTp -rl1G : •* Address Z p ,Phone 7 ! Contractor's Name S �yLicense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL,REPLACEMENT DESTRUCTION LJ {�) PUMP INSTALLATION F7 SYSTEM REPAIR l7 OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ! 9 1� Industrial U Open Bottom []Manteca Dia. of Well Excavation F. U Domestic/Private F-1 Gravel Pack [ Tracy Dia. of Well Casing t Public [_j Other [j Delta Type of Casing V Irrigation Approx. []Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State Work Done y" J Well Destruction LJ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION)< REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is i available within 200 feet.) } Installation will serve: Residence _ Commercial Other >_ Number of living units: s Number of bedrooms Lot size Character of soil to a depth of_3 feet: Water table depth S SEPTIC TANK Type/Mfg Capacity Zlf�i No. Compartments Z Method of Disposal PKG. TREATMENT PLT. F' Type/Mfg Capacity C� SEWAGE SYSTEM Distance to nearest: Well Foundation :Property Line C7" DESTRUCTION �i N LEACHING LINE U No. & Length of lines Total length/size -7O k DD !c J i Property FILTER BED � Distance to nearest: Well 100 Foundati on .10 Y P Y Line ( r7 'f SEEPAGE PITS Depth Size " r' Number ' €, SUMPS LI Distance.to nearest: Well 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 n�J� ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit ismissued, 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 ssued, 1 shall employ persons subject to workmanes compensation laws of California." The applic n all for 1 re i ctiogs. Complete drawl on reverse side./ Signed X 1 Title: or Date: y� FOR U M USE'DNLY 11 StK 466-6781 Application Accepted bliihM� Area F� lv ? Lodi 369-3621 g Additional Comments: Pit or Grout Inspection by s� Date y Manteca 823-7104 Final Inspection by Date ��t��o Tracy 835-6385 r \ Applicant - Return all copies to: E i onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 1 FEE BASE AMOUNT DUE' AMOUNT REMITTED RECEIVED BY DATE �2PERMi• # INFO hep, � � +� .�" � , <� w. - r � � - �• � e 10/82 500 (� EH 13-24 REV. 10/82 14-26