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31 0�1\�3 APPLICATION FOR PERIM7 SAN JOAQLi` LOCA n-ALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 0' 3 PERMIT N0. C1 W,-3 3 'G1DATE 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 SanJoaquinLocal Health District. Job Address 146T66 At, zVnl 9 D Subdivision Name Owner's Name O&[9N.A Address Phone Contractor's Name„1. /�UL��-� License No. , i�`R Phone 7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE OF WELL PROBLEM AREA ❑ Industrial U Open Bottom 7 Manteca U Domestic/Private 7 Gravel Pack ❑ Tracy P bl' D CONSTRUCTION SPECIFICATIONS Dia, of Well Excavation _ Dia. of Well Casing (] uis [j Other � eta Type of Casing Irrigation Approx. [] Eastern Depth Specifications FiCathodic Protection Depth of Grout Seal ❑ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done El 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 L_1REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve:- Residence _V Commercial _ Other Number of living units: �_ Number of bedrooms Lot size &o , Character of soil to a depth of 3 feet: Water Water table depth SEPTIC TANK EJType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well '"~'Foundation Property Line's DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED •� Distance to nearest: Well L” ` Foundation OOL" Line SEEPAGE PITS [) Depth Size Number I SUMPS Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS CI 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 shall employ persons subject to workman's compensation laws of California." The applicant %must , all frequired inspections. Complete drawing on reverse side. Signed X—��¢` /lG..� Title: 0AeLo5-Z �J' Date: ��" e- FOR DEPARTMENT USE ONLY ^� Application Accepted by Area j 3 Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Q� �, Manteca 823-7104 Final Inspection by Date 7 Li Tracy 835-6385 Applicant - Return all copies tvl7nvironmental 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 � 0o j� U � 13 EH 13-24 REV. 10/82 14-26 10/82 500