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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT ,�J2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-0781 DATE ISSUED_�_kp 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/Gr install the work herein F 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 Sp Joaquin Local Health District. Job Redress Subdivision Name Owner's Name ddress rgJ _" Phone 3 Contractor's Name License No. 7Q C,2X/ Phone 12�3Tt33 TYPE OF WELL/PUMP WORK: NEWIWELL F_� WELL REPLACEMENT DESTRUCTION V" PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER F-1 I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (J� FOUNDATION AGRICULTURE WELL ,'OTHER WELL PITS/SUMPS �?] INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q� I� Industrial U Open Bottom Manteca Dia. of Well Excavation ` U Domestic/Private [] Gravel Pack Tracy Dia. of Well Casing lD Public F-1 Other Delta Type of Casing Irrigation Approx. Eastern Depth Specifications . � Cathodic Protection Depth of Grout seal 17 Geophysical v 1 Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well DiameterSealing Material (tap 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is LJ � / available within 200 feet .) Installation will serve: Residence,✓ Commercial _ Other l Number of living units: t Number of bedrooms Lot size Character of soil to a depth ofe3,.feet: `r Water table depth SEPTIC TANK Type/Mfg rOn , - Capacity _L1D_— No. Compartments Z^ 1 PKG. TREATMENT PLT. Type/Mfg # Capacity !` Method of Disposal. SEWAGE SYSTEM Distance to nee rest: Well DO. Foundation �— Property Line DESTRUCTION I LEACHING LINE L� No. & Length of linesl� _ . Total length/size _�� i FILTER BED Distance to nearest: Well Foundation 4`�d Property Line i SEEPAGE PITS Depthr size+ - �� Number SUMPS t_I Distance to nearest:_. Well Foundation _4__ Property Line DISPOSAL PONDS ❑ E 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 rulesfand 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." cContractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued,' I shall empl persons subject to workman's compensation laws of California." C The applican for re ired inspections. Complete d s c � drawing on reverse side.-- // ; f Signed x Title: /(Z(,clk. 4 Date: 6, 6 ARTMENT US ONLY ` FO DEP Application Accepted by —— AreaD� RQ 5tk 466-6781 Additional Comments: " Fadi 369-3621 Pit or Grout Inspection by ' i Date ` Manteca 823-1104. Final Inspection by Date Q Tracy 835-6385 Applicant - Return all copies Environmental,.He .Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO L3 S 1 10/82 500 EH 13-24 REV, 10/82 14-26