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APPLICATION FCR.PERuIT .. SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. r� � Telephone (209) 466-6781.: 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 welllpump and the Rules and Regulations of the S n Joa uin Local Health District. Job Address42 Subdivision Name Owner's Name ZA-f Address .� Phone (p Contractor's Nam License No. Phon - Q TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS iU Industrial LJ Open Bottom Manteca Manteca Dia. of Well Excavation L_I Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Publ� is❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout Ljother Surface Seal Installed by i- Repair Work Done ElType of Pump H.P. State Workrpone_ -- Well Destruction U Well Diameter " ` Sealing Material (top 50') J - Depth F Filler Material (Below 50') TYPE OF SEPTIC WORK: 'NEW INSTALLATION _-REPAIR/ADDITION LJ (No e tic tank or seepage pit permitted if public sewer is � available within 200 feet.) Installation will serve: Residence= Commercial _ Other _ Number of living units: Number of edrooms Lot size r Water table depth • 0, 'F-" Character of soil to 'a 'depth of 31 -feet ,p , - -- SEPTIC TANK ❑y�Type/Mfg' *r r Cil 1 Capacity p _�,-No�Compart nts e7( PKG. TREATMENT PLT. ❑ Type/Mfg l _"'�""rCap- aeity Method of Dispos9l fcz- Foundation rProperty Line �e - SEWAGE SYSTEM. ❑ Distance(?,; Well[� DESTRUCTION . ti -IIm-L-EAGHTNG-LINE-c ^-`"jJ_NorM&-Length of lines Total length size - FILTER BED ' ❑ Distance to nearesrt: Well Foundation Property Line t SEEPAGE PITS � Depth Size Number� r / SUMPS Distance to nearest: Well /SQ Foundation _Z0 _ 'Property Line DISPOSAL PONDS 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 Dist"r-ict. Home owner or fieerised agent's signa=ure cerfif z fhe foil owing: I certiify that -1 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 viorkman, compensation laws of California." Contractor's hiring or sub -contras ting-signature-certifi-es-the-foRHowing.-"-I--certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensatioh laws of�California." The applican ust ca f all required inspections. Compleie�d�ra;ing g{i revers e.side� n� Signed K 1,. }= Ti-t.l.e;,�'= Datee?/ OR DEP RTMENT USE -ONLY r ❑ Stk 466-6781 Appli ion Accepted by --Area Lodi 369-3621 Additional Comments: - - �-- Date Manteca to S"23- -71'04 Pit or Grout Inspection by LJ Final Inspection by Date 1 .. Tracy 835-6385 Applicant - Return all copies to: Environmental He th Perm- it/Serv'ices 160CE..Hazel.toF A ��y0. Box 2009, Stk., CR 95201 MITTERECEIVED BYDATE �f7E�Q4 (�1 �iW4 PERMIT NO.. -FEEASE--AMOUNT_DUE___ - .AMOJNT,REj___INFO Qf O U 10/82 500 EH 13-24 REV. 10/82 14-25