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E -f !� APPLICATION FOR PERI4_T I SAN 70AQL N LOCAL H=4.LTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED _1� -�Li (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 the Rules and Regulations of the San Joaquin Local Health District, Job Address - Subdivision Name r Owner's Name Address/ jjp Phone { Contractor's Name License No, 2-274 Phone TYPE OF WELL/PUMP WORK: NEW WELL [ WELL REPLACEMENT [{ DESTRUCTION (J " PUMP INSTALLATION SYSTEM REPAIR OTHER U l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation F-1 Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing F ❑ Public ❑ Other Delta Type of Casing 71 Irrigation Approx. Eastern Specifications F-1k Cathodic Protection Depth IDepth of Grout Seal I ❑Geophysical ❑Other Type of Grout • Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Q Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') O TYPE OF SEPTIC WORK: .NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other m a T � Number of living units: / Number of bedrooms _ Lot size 5�� Character of soil to a depth of 3 feet: 444,11-1 Water table depth. /,2,0�/ SEPTIC TANK E!r' Type/Mfg !:S� Capacity 146.&0 No. Compartments ` PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well � Foundation /d Property Line 5A, ' DESTRUCTION ❑ ' LEACHING LINENo. & Length of lines — �/� Total length/size /;Z0 Z,,44- _-2- FILTER FILTER BED Distance to nearest: Well Foundation /(� - Property Line $fit 1 SEEPAGE PITS Depth ,2 5 IJ— Size -33 " Number 3 SUMPS LI Distance to nearest: Well /pQ Foundation /d Property Line DISPOSAL PONDS r 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, l 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 workmanIs 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant myfit call for all equired inspections. Complete drawing on reverse side. Signed X . Le Title: }�L[d• _ Date: Y-A,*0' F EPARTMENT USE ONLY Application Accepted by, Area _ ` ❑ Stk 466-6781 Additional,Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 623-7104- Final Inspection by Date r L Tracy 835-6385 Applicant - Return all ca ies En PP P o: vironment l Health .ermit Services 1601 E. Hazelt n A P.O. Box 2009 k 520 / o ., .D. o Stk.,, CA 9 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i INFO EH 13-24 REV. 10/82 10/82 500 14-26