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I �i 'i APPLICATION FOR PERMIT SAA ]OAQLiN LOCAL,HEALTH DISTRICT i! I! 1601 E. HAZELTON AVE., STOCKTONI, CA PERMIT NO. 'i_-_ 3S I Telephone (209) 466-6781 DATE ISSUEDJ4-1 T -�L �I PERMIT EXPIRES L YEAR FROM DATE ,ISSUED (Complete.in Triplicate) I - ' Application is hereby made':Ito the San Joaquin Local Health Di strict'for a permit to construct and/or install the work herein described. This application is made in compliance with Sar 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, l/ Jab Address z8 a :E Subdivision Name ✓`//�,w-711 Owner's Name Address Phone Contractor's Name License No. 32- 7 Phone. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [{ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES_- _ AISPOSAL,FLD.- _ _ PROP..-LINE. I FOUNDATION AGRICULTURE WELL OTHER TELL PITS/SUMPS INTENDED USE " TYPE OF WELL PROBLEM AREA ', CONSTRUCTION SPECIFICATIONS q ' IJ Industrial ilLjOpen-Bottom-- d ManEeca .Dia:•of- Well-Excavation- = - --� � ^"' �J ❑ Oomestic/Private II❑ Gravel Pack ❑Tracy Dia. of Well Casing I Public other Delta S ❑ �'❑ ❑ Type of Casing Irrigation ° Approx. ❑ Eastern Specifications Cathodic Protection Depth .�� Depth of Grout Seal ❑Geophysical Type of Grout A ❑Other I! Surface Sej_lnstalled by ' Stte Work .Done Repair Work Done ❑ Type,'of Pump � H•P• a - Well Destruction ❑ Well Diameter r_- Sealing Material (top 50')7_ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW'IINSTALLATION Kil RFPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Resi'ence Commercial _ Other I Gta.alVumber of bedrooms Lot size /ljp � Number of living units:i .. � _ Character of soil ��!Type/Mfg ' epth of; ?feet: Water table depth _. SEPTIC TANK fl� a� Capacity QG No. Compartments _ - PKG. TREATMENT PLT. ❑ I�Type/Mfg ,, Capacity �,T Method of Disposal 11 �� , , 'Pro erty Line S SEWAGE SYSTEM 0 Distance to nearest: Well 1 0 Foundation l P DESTRUCTION ❑ LEACHING LINE LTJ f No. &°Length of lines Total_len.gth/size FILTER BED ❑ Distance to nearest: Well 19_�Foundation_ _ cp Property Line ! - j3 3 SEEPAGE PITS � Depth IS � Size �• Number SUMPS ❑I 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 HealthfDistrict, ' Home owner or licensy that in the performance of the work for which this ed agent's signature certifies the following: "I certif Pe is issued, I shall not employ any person in such manner as to become subject to workman6 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, IIshall employ persons subject to workman's compensation laws of California." r The applicant must call far all required 'nspections." Complete drawing on reverse side. Signed X - Title: x� Da !� ��Z II F R DEPAR T USE 0 Y `;•= 1� � �. Application Accepted by -Area �: ❑ Stk 466-6781 ' `'� Lodi 369-3621 Additional Comments: Pit or Grout Inspection by ` Date ❑ Manteca 823-7104 ' Date ❑ Tracy 835-6385 Final Inspection ',by Applicant - Return all copies to:, Environ tal Health Permit/Services 1601 E. Hazelton Ave. F.O. Box 2009, Stk., CA 95201 IFEE BASE 'I.AMOUNT bUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. O 10/B2 500 EH 13-24 REV. 10/82 II 14-26 it _