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�E APPLICATION FOR PERMIT . SAP{ JOAQbIN LOCAL HEALTH -[DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 465-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 f the ran.Joaqu Local Health District. Job Address 16sion Name Owner's Name 14 9,f kP Address Syh.ri Phone Contractor's Name log,License No.// Phoney TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION L PUMP INSTALLATIONSYSTEM REPAIR OTHER J , 1DISTANCE TO NEAREST: SEPTIC TANK �{ SEWER LINES Li DISPOSAL FLD. ,5 0 .� PROP. LINE /-f FOUNDATION %Q t AGRICULTURE WELL OTHER WELL —-- - PITS/SUMPS 9 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ri J Industrial U / Open Bottom Manteca Dia. of Well Excavation S L) Domestic/Private Gravel Pack Tracy Dia, of Well Casing ti Public F-1Other ❑ Delta t Irrigation Type of Casing Y r—ot 52fe PVC/ Li 4 �� D Approx. [� Eastern Cathodic Protection Depth Specifications - Depth of Grout Seal Geophysical lVfOther QRI/t�( Type of Grout LAe f Surface Seal Installed by e2;, -.-O N � Repair Work Done -Type of Pump H.P. State Work Done - Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM Distance to nearest: Well - DESTRUCTION Other Lot size Water table depth _ Capacity No. Compartments _ Capacity Method of Disposal Foundation 'Property Line LEACHING LINE L No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 74 L i0 '1 SEEPAGE PITS F-1 Depth 1 Size Number SUMPS L Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS ❑ ! a I hereby certify that I have prepared thisrapplication 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 persoh in such manner as to become subject to.workman' compensation laws of California." Con tractor'Vhi"ri+ig'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 •pe ons subject .to workman's'compensatio_n.laws of California." The appli mu t c 11 or re i e inspections. Complete drawing on re erse side. Signed X� Titley Date: 0 DER RTMENT USE ONLY Application Accepted by Area 16 Stk 466-6781 l r Additional Comments: A It Lodi 369-3621 r , - Pit or Grout Inspection by Date � � L Manteca 823-7104 ,[,}o. Final"`Inspection'by Date 'jam 6 -� y Tracy 835-6385 47 Applicant - Return all copies tv:. Envi mental Health Permit/Services 1601- E: Hazelton Rve., P.O. Box 2009, St k., CA 95 ��..[ FFEE BASE AMOUNT DUE.--' AMOUNT REMITTED REGEVVED BY DATE PERMIT NO. ��. ��i►� �3 V p 1-3 - gLf - I J.r -_-. _-... I_ «-- _ .,._ ..�.. _ 10182, 500~ EH 13-24 REV. 10/82 �}ritd► "