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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT z —7 - ! 1601 L. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 �7 7 PATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.ir Triplicate) Application is hereby made to the San Joaquinr 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 p .� Subdivision Name Owner's Name L Address Phone Contractor'siName V � E- � _ License No. Phone 5 TYPE OF WELL/PUMP WORK: �i. NEW WELL ❑ WELL REPLACEMENT.r o DESTRUCTION W PUMP INSTALLATION SYSTEM REPAIR �.,; �� ✓ :/e OTHER w U � ) ,s �_"DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE m_�_„�� ”�:'"„A_ .`�•FOUPITS/SUMPS AGRICULTURE WELL OTHER WELL I n INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Industrial i! U Open Bottom Manteca Dia, of Well Excavation �1 k ^ Domestic/Private i; Gravel Park Tracy Dia. of Well Casing Public EJOther Delta Type of Casing LjIrrigation III. Approx. Eastern Specifications � Cathodic Protection ,` _� --..�&� �Depth �....�., Depth of Grout Seal — 1-1 GeophysicalE Type of Grout L10ther ,. II Surface Seal Installed-by rkPu-"P- 1 x- Repair WoDone El Type, Pumpr �” H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') F — Depths Filler Material (Below 50') V TYPE OF SEPTIC WORK: NEWPINSTALLATION ❑ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is !` available within 200 feet.) Installation will servell. Residence >—< Commercial —;)L— I Ae-Y C 5 Number of living units:18 Number of b�oams Lot size e Character of soil to a depth of 3 feet: _ __ __Water table depth itCapacityb No. Compartments _ SEPTIC TANK 7y pe/Mfg PKG. TREATMENT PLT. #Type/Mfg Capacity Method of Disposal SEWAGESYSTEMd Distance to nearest: Well _— Foundation __t= Property Line k1 DESTRUCTION k Total length/size LEACHING LINE U No. & Length of lines FILTER BED E Distance to nearest: Well _ Foundation Property Line --',SEEPAGE PITSID IDepth Size'n a Number , SUMPS Distance to nearest: Well `� r Foundation Property Line 1 , 1,0I`SPOSAL 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. kl Home owner or licensed agent's signature certifies the following;. "INcertify that in_rthe per df 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 Californiaic Co ctor's hiring or sLb-contracting signature certifies the following:y:-I-certify that in the performance of the work for which a this p t is issue I`shal1 employ persons subject to workman's compensation laws of California." The applica ca 1if r a re fired inspections'. }Gomplete'd ing an revg fide. p ' — Cq/� Date: �J !„ r._ Title:, Signe ' ar' F R DEPARTMENT USE ONLY { Stk 466=6781 ' Application Accepted by QiJ�I =? Area � . 0 Q, Lodi 369-3621 Additional Comments: 'iDate X Manteca 823-7104 Pit or Grout Inspection a, Final Inspection�,by Date : ❑ Tracy 835-6385 .I Applicant - Return all yapies to: Environmental Health Permit/Services 1601'E. Hazelton Ave.,uP.0iyBox 2009, St k., CR 95201 I ` FEE BASE ib AMOUNT DUE AMOUNT REMITTED -RECEIVED BY -DATE PERMIT NO. INFO � �''pI 10182 500 , EH 13-24 REV. 10/82 14-26