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�•�.....:.� •rte T APPLICATION FOR PERMS� 2 8 oUf 3 ! B3 PERMIT NO. Jr 03' f SAN OOAQlii"; LOCAL HEkLdH 31STR 1601 E. HAZFLTON AVE., STOCKTON, CA PATE ISSUED Telephone (209) 466-6781 ; PERMIT EXPIRES 1 YEAR FROM DATE ISsl1SAN JOAQDiN LOCAL , _ HEALTH DISTRICT p 43_o7a rr� (Complete in Triplicate) ( �'�p �J. �/ �� erein -it to Construct an, , sor}No.h1862rfor ewell/Puppn f 549 for sewage Application is hereb1icationoisthe madeSar inJoaquin compliancelwithlSanDJoaquin CountypOrdinance f� Cr 7 (described. This app ® _ and the Rules and Regulations of t e San Joao,uin Local Heal Subdivision Name phone ITd 4 .lob Address Address phone # Owner's Name ' License:No. Contractor's Name ❑ DESTRUCTION ❑ , NEW WELL WELL REPLACEMENT OTHER U Q TYPE OF WELL/PUMP WORK: PUMP INSTALLATION ❑ SYSTEM REPAIR U PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. � AGRICULTURE WELL ��- OTHER WELL �— PITS/SUMPS 156 } _ FOUNDATION PR08LEM AREA CONSTRUCTION SPECIFICATIONS �� j It TYPE OF WELL �dS� � ® 1� INTEN�_DEO USE TYP �~ Dia.of.Well Excavation_ Op ❑Manteca �4- en Bottom_ Dia. of Well Casing k T Industrial. ,_- �Gravel Pack Tracy ❑ `^ _ {Domestic/Private ] fE __ ❑ ❑Other ❑Delta Type of Casing Public Approx. tern Specifications ❑Eastern Irrigation --- Depth Depth of Grout Seal ❑Cathodic Protection Type of Grout ❑Geophysical Surface Seal Installed by ❑Other State Work Done Type of Pump � H.P.ea Repair Work Done ❑ + Sling Materia} (top 50') Well Destruction ❑ .Well Diamete1.r 1 Filler Materia} (Below 50') I Depth blit sewer is _ No septic tank or seepage pit permitted t Public REPAIR/ADDITION LJ ( available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION LI ether t Commercial installation will serve: Residence- Lot size �_�— Number of living units: i Number of bedrooms �� Water table depth Character bf soil to a depth of 3 feet: Capacity _�.� No. Compartments y e Mf Method of Disposal SEPTIC TANK r-1 T P / 9 Capacity J�.� PKG. TREATfENT PLT. [J TYPe/Mfg Foundation Property Line SEWAGE SYSTEM C] Distance to nearest: Well DESTRUCTION Total length/size No. & Length of lines property Line LEACHING LINE U Well Foundation _ — Distance to nearest. �� FILTER BED ❑ Number _ Lin Size _ _—. _ = - 'Property' e�_� @g SEEPAGE"PITS ❑ Dept .��—.. _ _ Foundation Distance to nearest: Well Y SUMPS �—I DISPOSAL PONDS ❑ )repared this application and th,oatuenwLocalork �Healthll be dDistrone rict�cordof the oork for which this I I hereby certify that 1 haveP p °I certify-that in the performance ensation laws,of California.' ordinances, state laws, and rules and regulations of the San q I certify that km the performance of t'I work for which any person in such manner as to become subject to workman comp Home owner or licensed agent's signature certifies the fmalowtinf permit is issued; I shall not employ persons subject to workman's compensation laws of California: r` D � Contractor's hiring or sub-contracting signature certifies the following: this permit is issued, i sha 1 employ P ' 4,r1 r quired in tions. Complete drawl n on reverse si e. The applicant m call,_for Ti le: Signed X ONLY3 Stk 466-6781 Area _ ❑ 369-3621 Lodi a Application Accepted b Manteca 823-7104 835- Additional Comments: ` Date 1 U 7 ❑ Tracy 6385 Pit or Grout Inspection' y pate Final Inspection by 16 co ies to vironmental Health Permit/Services 01 E. Hazelton Ave., P.O. Dox PORM]TSNO. CA 95201 Applicant - Return all P RECEIVED 6Y DATE k AMOUNT DUE AMOUNT REMITTED 3_Q3 FEE BASE INFO -1 2:) 1D/82 506 EH 13-24 REV. 10/82 40