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Iy { APPLICATION FOR PERMIT SA.N JOAQUiI! LOCAL H4-ALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.2F3 33 k Telephone (209) 466-6781' PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED f (Complete in Triplicate) -_, 01�w l� f-bra-0 Application is hereby made to the n Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ma'e 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, Jab Address Lot�pj rrrn� k/,,,y ISMO Subdivision Name Owner's Name F G Address" �- � S!� Phone Q f Contractor's Namer License No. Phone l TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMLNT DESTRUCTION W PUMP INSTALLATION SYSTEM REPAIR LL7 OTHER �� l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W Industrial U Oper�Bottom Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy Dia, of Well Casing ; 17Public .� OtherDelta 71 Irrigation z Type of Casing O Approx. 71 Eastern Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal 1 U Other Type of'Grout #+ Surface Seal Installed by 0 Repair Work Done D Type of Pump # H.P. State Work Done Well Destruction U Well Diameter-i Sealing Material (top 50') Depth t Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW [NSTALLATIDN L� REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is I available within 200,feet.) i Installation will serve: Residence _ Commercial _ Othei zj fJ Number of living units: �'_ Number of bedrooms _ Lot size Character of soil to a depth of 3 feet: Water table depth J Z7 SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal ^� SEWAGE SYSTEM ��--11 Distance .to nearest: Well Foundation Property Line DESTRUCTION L 1 I LEACHING LINE No. & Len th of lines 9 J r— '70 Total length/size •�•r � }� FILTER BED ❑ Distance to nearest: Well Foundation Zz_:) � Property Line = i SEEPAGE PITS F-1 Depth i Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that C•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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this r -g permit is issued, I shall not employ any person in such manner ds to become subject to workman, compensation laws of California." Contractor's hi 'ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is -sued, I shall emp```lo��y per- subject to workman's compensation laws of California." The appli an m allre��p>ee,,Ions. Compl tong on reverse side.Signed X Title: Date.. FOR DEPART . } Application Accepted by rea Stk 466-6781 Additional Comments [� Lodi 369-3621 Pit or Grout Inspecti n Date Manteca 823-7104 Final;Inspection by Date — Tracy 835-6385 .Applicant - Return all cc e to: Environmental Health Permit/Services 1 C1 E. Hazelton Ave., P.O. Box 2009, Stk., CA ,95201 FEEO BASE OUV DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INF 02- EH 13-24 REV. 10/82 10/82 500 �� k 14-26 (,�