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APPLICATION FOR PER.MI T SP.N JOAQUi" LOCAL HEALTH J:S7RICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3- 5�b } - Telephone (209) 466-6781 DATE ISSUED744f3 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 Hea th District. Job Address Subdivision Name - Owner's Name �! - Address Phone Contractor's Name - License-No. - Phone !6/" am- _ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE S FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! J Industrial ❑ Open''Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private _ [].Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑ Othq i ❑ Delta Type of Casing Irrigation !Approx. [] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by - -. ` Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter' Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: "NEW INSTALLATION U "REPAIR/ADDITION- X (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial i Other A Number of living units: —4-1 Nunber of bedrooms LI bt size 90/;tc. pp f n Water table depth Character of sail to a depth of',3 feet: �s `72— SEPTIC .,� SEPTIC TANK �} Type/Mfg }/y+,c aI - �_' Capacity 2 No. Compartments ` Capacity Method of Disposal PKG.' TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM Distance to nearest: Well '200 Foundation ,ep Property tine DESTRUCTION A L - LEACHING LINE ❑ No. & Length of lines Total length/size If �i FILTER BED Distance to nearest: Well ZOp _Foundation 1,e Property Line SEEPAGE PITS ❑ Depth I! SizeJ Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 workman`; 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." r in ectians. Complete drawing o/n�reverse e. The applicant must ca 1 f r al requi Signed X ( Title: Date: 4�Jf E DE TMENT ONLY ® � Stk 466-6781 Application Accepted b Area - —"� ❑ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by __ Date LV- Tracy 835-6385 Applicant - Return all copies to: Environmen ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i` E t AMOUN7 REMITTED RECEIVED BY iiGCCATE q p PERMIT NO. [FE BASADUE INFO 3 10/82 500 EH 13-24 REV. 10/82 14-26