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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 9 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. a Telephone (209) 466-6781 DATE ISSUED I�4 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�1 F Subdivision Name Owner's Name /Z, ` S _ Address Phone Contractor's Name 17 License No. Phone 4 �. l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION U PUMP INSTALLATION ] SYSTEM REPAIR OTHER ❑ �] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE pJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 11 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1! 0 industrial U Open Bottom El Manteca Dia. of Well Excavation Domestic/Private F-I Gravel Pack F-1 Tracy Dia. of Well Casing 1 !] Public [j Other ❑ Delta Type of Casing F1 Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal L-1 Geophysical Type of Grout ' F-10ther- Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth _ Filler Material (Below 50') J TYPE OF 5£PTIC WORK: NEW INSTALLATION U REPAIR/ADDITION !�J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: �_ Number of bedrooms Z Lot size lbi_3X 0 `1 Character of soil to a depth of 3 feet: C" Water table depth -. + o SEPTIC TANK Type/Mfg ity 1 ZOO No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Septic Tank 0 Distance to nearest: Well 17-0 Foundation fie_' Property Line,, 7� ' Destruction ; LEACHING LINE No. & Length of lines / ©` Total length/size FILTER BED F-� Distance to nearest: Well )2�0 Foundation 1 D ` Property Line 1 p lo SEEPAGE PITS Depth 2,1 Size All Number SUMPS LJ Distance to nearest: Well J 7-0 Foundation J O Property Line f O DISPOSACPONDS Cj ` 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 hiringxor'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." i The applicant must c ll for all required in ctions. Complete dra ing on reverse side. Signed X - Title:- Date: 1�/& E Z— FOR DEPARTMENT USE ONLY Application Accepted_by Area © Stk 466-6781 Additional Comments: Lodi 369-3621 - — -. Pit or Grout Inspection by bate Manteca 823-7104 Final Inspection by r Date L Tracy "835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O—Box 2009, Stk., CA 95201 f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE 5 PERMIT N0. INFO - p 7 " ; L-7-2-7 EH 13-24 REV. 10/82 10/82 500 14-26