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APPLICATION�FOR-PERMt-T------ y, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA *r PERMIT NO. y 1 Telephohe (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t !Application is hereby made to the San Joaquin Local Health District for a permit to construct and/er 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 AddresszdA S Subdivision Name _ 6' Owner:s NameX Jt ijo.1n, Addres;i RG, San 3Z _ Phonw- £`Contractor's Name License Na. Phone I ` TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR L OTHER ❑ yf - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / DISPOSAL PLO. (PROP. LINE �. N _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS' "•� ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPEC-IFICASIONS u �• fk �,,,_ —.. 5o R r Iy Indusfrial 'Open Bottom Manteca Dia. of Well Excavation J<Domestic./Private D.Gravel Pack ❑ Tracy Dia. of Well Casing 4� Y Public Other Delta Type of Casing AGt� ryry Ljlrrigatidn Approxi_ [] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal P Geophysical - Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501 w Depth Filler Material (Below 50'} '* r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J .(Nd septic 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 bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Y� Type/Mfg Capacity No. Compartments 4 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE,SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ f t LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED Distance to nearest: Well Foundation Property Line SUMPS ❑. Distance to nearest: Well Foundation 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 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 wvrkmang compensation laws of Californiac f the work for which Contractor's hiring or sub-contractiny.signature certifies the fallowing: "I certify that in the performance oh this permit i.s issu d, [ shall employ persons subject to workman's compensation laws of California." The applicant m 1 e c ions. Complete drawing on reverse si e. �7 Signed X Title: Date: yJ+ ` F DLPAR ENT US LY Application Accepted by rea ❑ 5tk 46fi-fi7$1 � Additional Comments: � Lodi 369-3621 a 7104 Pit or ro Inspection by Date Manteca 823-6385 i Final Inspection by Date �� Tracy 835-6385 Applicant - Return all copies to: Environmental He th Permit/Services 1601 EaKzelton Ave., P.O. Box 2009, Stk., CA 95201 7—( ' I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. } INFO p fLA Al . c, 10/82 500 t: AA EH 13-24 REV. 10/82 14-26