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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. / 1+7 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address I G IRPDXI GJs%ybdivision Name Owner's Name V C?W2 Ifkpg Address -5A0)e Phone >t 3, Contractor's Name 71M CAQGlte License No. 2937/3 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION lI' PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (" Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing t7 Public F-1 Other Delta Type of Casing Lj Irrigation Approx. [:] Eastern Depth Specifications Cathodic Protection Depth of Grout Seal 17 Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') J Depth Filler Material (Below 50') �/" 67 TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is pU available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: j Number of I SAM-0y Lot size CR m(x Character of soil to a depth of 3 feet: J/'M-0 y Water table depth SEPTIC TANK Type/Mfg p2rcWs1' Capacity /700 6r94 No. Compartments 2 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal i SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION 3 LEACHING LINE No. & Length of lines - 7y Total length/size „2/V FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 workmant 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, I shall employ persons subject to workman's compensation laws of California." The applicant call for a 1 requir inspections. Complete drawing on reverse side. Signed X 2 Title: C 0&7rAA'-T0 R. Date: `7�' � `� - �� PARTMENT USE ONLY 1'Z N Application Accepted by Area _LJ_ Stk 466-6781 Additional Comments: V Lodi 369-3621 — Pit or Grout Inspection by Date �/' Manteca 823-7104 Final Inspection Inspection by AZ geq Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental H th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY — DATE -p PER;MIIT NO. 7 1 INFO 6 tO, .,q2 O la EH 13-24 REV. 10/82 10/82 500 14-26