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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED DATE- ISSUED 111_ (Complete in Triplicate) Z U1 A y 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. �N �� U�'U�� i Job Address BiYd Road (35'00 jr�. B_1ewe_tt)_ Subdivision Name ' Owner's Name Robert H. "Brown, Sr . Address 874 E . Woodward,Manteca Phone (209) 239-492 Contractor's Name SELF License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK jp! SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { INTENDED USE TYPE OF,'WELL PROBLEM AREA ;• ijCONSTRUCTION.SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation .� F-1 Domestic/Private E]Graver Pack; ---❑Tracy----—Dia---of Mell Casing— Public asing—Public ❑Other ❑ Delta Type of Casing F-1 Irrigation Approx. ❑Eastern Depth Specifications ❑Cathodic Protection p ' Depth of Grout Seal ' Geophysical Type of Grout 117 Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done SN Well Destruction ❑ Well Diameter Sealing Material (top 50') r 4 Depth Filler Materiall(Below 50') 1r! 2i �. TYPE OF SEPTIC WORK: NEW 1NSTALLATION)M REPAIR/ADDIT10N4 0. '-(No septic tank or seepage pit permitted if public sewer is ' r 4 Q • available within 200 feet.) Installation will serve: Residence XX Commercial Other i s' Number of living units: 2 Number of bedrooms 2" Lot size 40 acres Character of soil to a depth of 3 feet:., - gravelly Los Robles 1oaltter•table depth �a] x SEPTIC TANK EXI Type/Mfg _ _ C-e m-e n t_ Capacity 2000 _No. Compartments_ -__ _ PKG. tREATMENT PLT. ❑ Type/Mfg + Capacity Method of Disposal f SEWAGE%SYSTEMDistance to nearest:' Well n/a Foundation __n f Property Line n DESTRUCTION LEACHING LINE ) No. & Length of,lines Total length/size 150 ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line j "! SEEPAGE PITS E]3I Depth — Size, j t ~ Number SUMPS LJ Distance to nearest:_ Well # Foundation Property Line DISPOSAL PONDSJN I ❑ x i 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 workmant compensation.laws of Cal.ifornia.". Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is ssued, I shall employ persons subject to workman's compensation laws of California." The applican ust call fS` 7 .equir-d inspections. Complete drawing on reverse side. Signed X Title: Secretary Date: 10-28--86 R DEPARTMENT USE ONLY Application Accepted byre"! rea ❑ 5tk 466-6781 f Additional Comments: ; LSA m 3 [:] Lodi 369-3621 % Pit or Grout Inspection 6y ate '�'� ❑ Manteca 823-7104 Final Inspection by Datef�- ❑ Tracy 835-6385 Applicant - Return all copies to: Environme a 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 EH 13-24 REV. 10/82 0,J4ip 10/82 500 14-26 _ y