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O APPLICATION FOR PER.MiT I �$ SA14 JOAQLIN LOCA'. HEALTH DISTRICT 1601 E. HAZELTOI AVE., STUCKTON, CA PERMIT NO. Telephone (209) 466-6781. DATE ISSUED .� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f kDmplete in Triplicate) '7 � E Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th`e work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No., 1862 for.lwell/pump and the Rule Re ulations of the San.Jooaquin Loc Health District. it Job AddreL1 (//r� Subdivision Name Owner's Name Addre r -� &&rX'i a e _ - 3s i" Contractor's Na License-No. Sr Qhs Phone-75-q-3AIyy a TYPE OF WELL/PUMP WORK: NEW WELL ❑ LL REPLACEMENT F-1DESTRUCTION �SYSTEM PUMP INSTALLATION REPAIR OTHER U „ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WILL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑Other Delta Type of Casing Irrigation Approx. ❑ Eastern ❑Cathodic Protection x_ Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout LJ Other W Surface Seal Installed by ,, r _1 Repair Work Done ❑ Type of Pump �i.l� H.P. State Work Done ` vV Well Destruction ❑ Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is (�} available within 200 feet.) C Installation will serve: Residence _ Commercial _ Other �1 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ? PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal } SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING EINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 3 SUMPS L-1Distance 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, shall not employ any person in such manner as to became subject to workman compensation laws of Cali'Fornia." Contractor's hi n or sub-contracting s Jcert"f9es the following: "I certify that in the performance of the work for which this permit i issued, ] sha 1 employ p je to workman's c ensation laws of California." The applica m c o al a uir s. Complete ing on reverse side.Signed X Title: Date:RTMENT USE Y Application Accepted by a ❑ Stk 465-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date 2 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental H lth 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 115 EH 13-24 REV. 10/82 10/82 500 14-26