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APPLICATION FOR PERMIT i SAN JOAQUiN LOCAL HEALTH DISTRICT ?] ^140 vvQ 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT INC. ��R A— A Telephone (209) 466-6781 rLyrt' DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1862 for well/pump and thel�Rules and Regulations of the San Joaquin Local Health District. Job Address 6' Z�5— Subdivision Name Owner's Name l/ 7eAae pIn/?pDiPFAddress LA/ Phone Contractor's NameLicense No. Phone ' 1 TYPE OFI�WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTIONg IINI PUMP INSTALLATION SYSTEM REPAIR LJ OTHER" DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS Jam' Industrial 1U Open Bottom Manteca Dia. of Well Excavation �b Domestic/Private Gravel Pack Q Tracy Dia. of Well Casing Public [ Other Delta Type J 4' yp of Casing XACI— L i Irrigation Approx. LJ Eastern Specifications Cathodic Protection Depth Depth f Grout Seal Iib P o ❑Geophysical � Type of Grout GE ❑Other Surface Seal Installed by i ✓ Repair Work Done. Type of Pump .rug H.P. _NJ� State Work Done �-- Well Destruction Well Well Diameter � �' Sealing Material (top 50') II Depth Filler Material (Below 50') TYPE OF"SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION lJ (No septic tank or seepage pit permitted if public sewer is ii�i available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Num4 of living units: Number of bedrooms Lot size Q Character of soil to a depth of 3 feet: Water table depth SEPTIC'I�TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg :, Capacity Method of Disposal SEWAGE;SYSTEM Distance to nearest: "Well Foundation Property Line DESTRUCTION ❑ i LEACHING LINE U No. & Length of lines, Total length/size FILTER$BED Distance to nearest: , Well Foundation Property Line SEEPAGE PITS CI Depth Size Number SUMPS , L—I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ' t 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;Jis 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 workman's compensation laws of California." i The ap.1ican must call for all re 'red inspections. Complete drawing n reverse side. qp Date: `-� 'f Signed!XY C Title: -- �/1,� FOR DEPA ENT USE ONLY / pI Stk 466-6781 Application Accepted by /��Gti•� Area "-- Additional CommentsLodi 369-3521 Date 6 's' Manteca 823-7104 ``P�r Grout Inspection by L� 1�Final Inspection by Date 7— ��'—�3 ❑ Tracy 835-6385 IIID Replicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 IE; :FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. iINFO �r 3 EH 13�I24 REV. 10/82 -2` t-6 �� 10/82 500 14'4'26 I�