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APPLICATION FOR PERMIT SAN JOAQLi; LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. �ID 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 Joaquin Local Health District. Job Address 103!0 N. ALpfNZ Rh Subdivision NameJS��9 Owner's Name A10- K 0 A MEVA&I Address SQ!trt0 � Phone Contractor's Name j ,&,Ot7 License No. tLZ i� 2_77 L Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT PUMP INSTALLATION SYSTEM REPAIR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA I l Industrial U Open Bottom F-1 Manteca U Domestic/Private F-1 Gravel Pack ❑ Tracy P bl' D It [] DESTRUCTION U OTHER U DISPOSAL FED. OTHER WELL CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing PROP. LINE PITS/SUMPS U is BASE L_J Other L_J e a Type of Casing V Irrigation I hereby certify that I have prepared this application and that the work will be done in Approx. [:]Eastern Specifications C] Cathodic Protection permit is issued, I shall not employ any person in such manner as Contractor's hiring or sub -contracting signature certifies the following: "I certify that Depth this permit is issued, I shall employ persons subject to workman's compensation laws of California." Depth of Grout Seal 17 Geophysical &7 Date: A Type of Grout U Other OR PAR ENT USE ONLY Stk 6-67 Application Accepted by Area PfZ Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 (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: 1 Number of bedrooms Lot size Character of of soil to a depth of 3 feet: 1—A V 01 Water table depth SEPTIC TANK [ Type/Mfg n e- —1%4- L Capacity 12,4,0 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM 1-1 Distance to nearest: Well I P Foundation Z/ Property Line7la DESTRUCTION LEACHING LINE No. & Length of lines � F Total length/size 170 X 7 - FILTER BED FILTER Distance to nearest: Well Q Foundation 119 Property Line SEEPAGE PITS Depth,� y l Size Number lz- BASE SUMPS Ll Distance to nearest: Well�� Foundation ii oto'' Property Line DISPOSAL PONDS ❑ PERMIT NO. 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. the for which this Home owner or licensed agent's signature certifies the following: "I certify that in the performance of work to become subject to workman compensation laws of California." permit is issued, I shall not employ any person in such manner as 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." The applicant must call for 11 required inspec'ons. Complete drawing onreverse side. &7 Date: A Signed X Title: OR PAR ENT USE ONLY Stk 6-67 Application Accepted by Area PfZ Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date 'r Manteca 823-7104 Final Inspection by :LW. G — Date awl ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental 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. INFOAl Lac� c EH 13-24 REV. 10/82 10/82 500 14-26 C?J N