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APPLICATION FOR PER.'•SiT SAN JOAQUiI, LOCAL " rALT DISTRICT 16CI E. HAZELTON AVE. STOCKTON, CA PERMIT NO. q q_:3 f 1 7 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUEDf (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. 18622for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �f kf Job Address Subdivision Name Owner's Name Address Contractor's Name �`)�4License No, 3,iffXZ-6 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR J OTHER J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation J Domestic/Private ❑ Gravel Pack F-1 Tracy, Dia, of Well Casing Public J Other ❑ Delta Ir•ri ation Type of Casing F, 9 Approx. E] Eastern Specifications J Cathodic Protection Depth } 1-1 Geophysical Depth of Grout Seal �- LJ Other Tyj)e of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State{Work Done Well Destruction J Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') Vv TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AIR,A DITION J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence /Y Commercial _ Other available within 200 feet.)1 "" r Number of living units: Number of bedrooms -3 Lot size Character of soil to a depth f.3 feet: Water table depth !?Q f SEPTIC TANK L] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINELT '" No. & Length of lines 1. Total length/size a' FILTER BED ❑ Distance to nearest: Well _ fie t"- Foundation /d / Property Line SEEPAGE PITS Depth a 51 Size irr p ��_ Number SUMPS L1 Distance to nearest: Well 04 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 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 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 subject to-workran's compensation laws of California." The applicant mu call for all-required inspections. Compl"ete drawing on reverse-side. Signed X �,, Title: Dater OE PA MENT USE ONLY Application Accepted by _ � Area Stk �4=66-6781 Additional Comments: ` ❑ Lodi 369-3521 Pit or Grout Inspection by Date —g`��^L7"�/ J Manteca 823-7104 Final Inspection by r Date �/ L y Trac835-6385 Applicant - Return all copies to: Environmental H—W, Permit/Services 1601 E. Hazelten ve„ P.0, Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 7 DATE Q PERMIT N0. INFO •�,.. ,�y5,s ..7��10_0 �- ,3�� 4 EH 13-24 REV/.10/82 �"10/82 500 1 14-26 F