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APPLICATION FOM PERM;; f SAN JOAQL•i!; LOCA! HFr'.LTH DISTRICT . . ..31983PERMi1T NO. X3'2 1601 E. HAZELTON 4VE„ STOCKTON, CA JI��: �u;. ^^-2� i Telephone (209) 466-6761 TE ISSUED PERMIT EXPIRES i.YEAR FROM DATE ISSUED �pp sP i ktb L� &I (Complete in Triplicate) EGi4EALY" 9%m-CT 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 Ian Joaqui Local Health District. Job Address Subdivision Name / Owner's Name Address /g(��', AL$ Phone as3 1 Contractor's Name License No. Phone —•� f i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U / PUMP INSTALLATION SYSTEM REPAIR L7 OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK //& ITSEWER LINES DISPOSAL FL 3� PROP. LINE ! FOUNDATION"" � j&7-� �- AGRICULTURE WELL OTHER WELL PITS/SUMPS (�y ` INTENDED USE TYPE OF WELL PROSL,�M AREA ) CONSTRUCTION SPECIFICATIONS I Industrial_, f I 3 Ll Open Bottom y, Manteca Dia _of,Well.Excavation , fV Domestic/Private Gravel Pack Tracy Dia. of Well Casing T , r Public F-1 Other Delta Type of Casing f V'Irrigation Approx. Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal a Geophysical t Type of Grout - ❑Other Surface Seal Installed by ea Repair Work Done EJ Type of Pump ,�}l�,�j H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 50') _ ~ Depth Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION F1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is T Installation will serve: Residence Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments A PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest- Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE LJ No, & Length of lines Total length/size FILTER.BED Distance to nearest: Well Foundation { Property Line F SEEPAGE PITS ❑ Depth Size Number SUMPS 11 Distance to nearest: Well Foundation F Property Line .a-=� ➢I�PDSAL'PONDS., .� •y,--.,,-�� T, _ .,� . .�,.,,R_ �: ter---�, �-r-- ��_-•,�...� - •=--s,�--�.....»,..-.�,. �,� -�,r::�,�, 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 shalla loy persons subject to workman's compensation laws of California." The applicant ust call f re red pections, Complete drawing on reverse side. Signed }( Title: Date: FOR D-77A"N,T�1�F.ONLY -�-r-- r---� Application Accepted by � Area 0(j ❑ Stk 466-6781 A Additional Comments: Lodi 369-3621 q Pit or Grout Inspectio b Date Q Manteca 823-7194 4 Final Inspection by -_-_.- Date L7 Tracy 835-6385 1 Applicant - Return all copies toil Environme 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE - BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO � LA �n f I .. f EH 13-24 REV. 10/82 „_ 10/82 500 14-26 f ,