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Y w APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 10-3 J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. U Oma— Telephone (209) 466-6781 DATE ISSUEp 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 aRegulations of the San Joaquin Local Health District. � r Job Address 'i` * Subdivision Name -�rt� Owner's Name Address g.0,40--'reWane Contractor's Named( .Q,rte S License No. Phone TYPE OF WELL/PUMP WGRK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ✓2'[, W kWy,� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FGUNDATION AGRICULTURE WELL OTHER WELL 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 17 Public F-1 Other Delta Type of Casing U Irrigation Approx. ❑ Eastern Specifications E]Cathodic Protection Depth F1 Geophysical Depth of Grout Seal Type of Grout [j J-Other 1.14rle-rIA40W Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top SO') / Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 141 REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence _ Commercial Other 4/41T Number of living units: Number of bedrooms_ Lot size .5�� "X � 7 Character of soil to a dep h of 3 feet: ✓ .10 - Water table depth SEPTIC TANK [�` Type/Mfg .�� Capacity 4e�.9-e _ No. Compartments .Z # PKG. TREATMENT PLT. �] Type/Mfg Capacity Method of Disposal a / LEACHING LINE Distance to nearest: Well Foundation Property Line No. & Length of lines 2 U 9 _ I /,r �� 9 / ( P�Lcd1/ ��10' 7�y4v � Total length/size FILTER BED Distance to nearest: Well,arb w gy-Foundation /m / Property Line �a/ SEEPAGE PITS Depth 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 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 ll loy persons subject to workman's compensation laws of California." The applica st 1 inspections. Complete drawing on reverse side. SignedX Title: _ tl ege'n Date: A MENT �j Application Accepted by FOR EPONLYGa Area E] Stk 466-6781 Additional Comments: �,-4 LIS- Ae-i" �,�- 'yS Lodi 369-3621 Pit or Grout Inspection by Date L-2 Manteca 823-7104 Final Inspection by Date 17 -1 `7- Tracy 835-6385 Applicant - Return a17 copies t Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 14-26 REV. I0/82 10/82 500