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APPLICATION FOR PERMIT SAN JOA%jN LOCAL.HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO, DATE ISSUED 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 ,oaouin Local Health District. C_�t Job Address 0 IF., P2Lh= bdivisian Name REV. 10/82 Owner's Name � Address /Q hone S( ... 42 Contractor's ` A License No, Phone TYPE OF WELL/PUMP WORK: NE4; WELL WELL REPLACEMENT DESTRUCTION U PUMP- INSTALL"ATION—F SYSTEM REPAIR OTHER DISTANCE TO NEAREST'SEPTIC TANK SEWER LINES I a DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL k OTHER-WEL:' J ' PITS/SUMPS! i INTENDED USE-- — --STYPE— OF -WELL --- PROBLEM AREA "F CONSTRUCTION SPECIFICATIONS IJ Industrial [j Open Bottom F—I Manteca Dia. of Well Excavation ! U Domestic/Private '"❑ Gravel Pack {Tracy Dia. of Well Casing Public Other F Delta i Type of Casing LjIrrigation Approx. F -]Eastern Specifications Cathodic Protectfon--..: Depth Depth of Grout Seal L7 Geophysical U Other � Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well"Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is ; available within 200 feet.) ! Installation will serve: 'Residence _ Commercial Other Number of living units: Number of bedroomsLot size Character of soil to a depth of 3 feet: Water table depth ,-34b SEPTIC TANK Y...& Type/Mfg �,[, f,Lp,�, Capacity_ No. Compartments PKG, TREATMENT PLT. F-] Type/Mfg -- — Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well ."� Foundation Property Line DESTRUCTION �• - i LEACHING LINE �� No. & Length of lines 20 Total length/size 1640 oZ 1 FILTER BED Distance to nearest: Well ` Foundation `� Property Line—u---_-_-�.-._ SEEPAGE PITS y� Depth Size Number # SUMPS �4Distance to nearest: Well Foundation Property Line 111 r DISPOSAL PONDS v I hereby certify that -I-ff e prepared this application and that the work will be done in ac ordance 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 omploy any person in such manner as to become subject to workman!; 6ompensation'laws of California." Contractor's hiring'"or sub-coniractin-l'-'signa-tune•certifiesthe-foi-l'owing: "I certify that,in tFie performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of/Cali'fornia." f The applic t must 11 for all required inspections. Complete drawing'on re se sidd e Signed Xr Title: ' V a J Date: 'y r J FO DEPARTMENT USE ON Y T t i Application Accepted by ow Area Stk 466-6782 Additional Comments: "' ,fir' Lodi 369-3621 Pit or Grout Inspection by 'Date F, Manteca 823-7104 Final Inspection by Date �T t{l Tracy 835-6385 / 4 Applicant - Return,al.l_copies to: Environmenta Health Permit/Services 1601 E. Hazelton ve.; P: O. Box 2009, Stk., CA 95201 r k a 4 J.� FEE INFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. C_�t t IJ 8V EH 13-24 REV. 10/82 b-�,-^ -e--^— •^-�- --- "--r--^10/82 500—� 14-26 k a 4 J.�