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/I 3• '00, APPLICATION FOR PERMIT r�A�p SA.N JOAQUiN LOCAL HEALTH Di$IRICT �/-/1601 E. HAZELTON AVE„ STOCKTON, CA PER _4h J. Telephone (209) 466-6781 � /` DATE ISSUED l ich 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 L al Health District, Job Address LL.. Subdivision Name Owner's Name - ,Ydl�� Address S��q`p Phone TV ��• Contractor's Name License No. ,��r'�/3�p' Phone �Pf f � TYPE'OF WELL/PUMP WORK:+"`s 'NEW WELL WELL REPLACEMENT DESTRUCTION pump°INSTALLATION” SYSTEM-,REPAIR OTHER U i DISTANCE TO NEAREST: SEPTIC TANK ��® SEWER LINES DISPOSAL FLD. _,J&LrPROP. LINE 3 FOUNDATION AGRICULTURE WELL OTHER WELL 4`a7pPITS/SUMPS #�# INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A, 1 !J Industrial U Open Bottom [] Manteca Dia. of Well Excavation jmestic/Private Gravel Pack Tracy Dia. of Well Casing � rz Public Other Delta Type of Casing LjIrrigation @ Approx. Eastern E � Cathodic Protection Depth Specifications r t. Depth of Grout Seat �Q /►�yam/. L7 Geophysical y Type of Grout ,--,,e 7 U Other ,9/ m�y -� � Surface Seal Installed b �e,R� +.r/ Repair Work Done ❑ Type of Pump Lt H,P, 3 s State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') f�1 } TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is i available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size r Character of soil to a depth of 3 feet: ' s�.'> ! Water table depth V 3 SEPTIC TANK ❑ Type/Mfg ; Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg .,. .°`_� Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well"` Foundation Property Line DESTRUCTION i LEACHING LINE U No.-& Length of lines ``�+ Total length/size ` FILTER BED Distance to nearest: Well Foundation Property Line r SEEPAGE PITS Cj Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL 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. 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 person sub' ct to workman's compen tion laws of California." The applicant must f all req e e drawing n ever -de. � Signed X le: Date: 1 9Aus F R DEPARTMENT USE ONLY Application Ac p d by Area 5tk X456-6781 x Additio ments: Lodi369-3621 f Date � i •Mantecaf823' 7104 Pit o�nspection . C Final Inspection by Date f7`f L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. zelton Ave., P.D. Box 2009, Stk\, CA 95201 FEE BASE AMOUNT OUE „,.:,AMOUNT REMITTED— , --RECEIVED BY -.DATE___ PERMIT NO.._^�` .�..»-. � b •. �.� +� w f EH 13-24 REV. 10/82 \_X—�� 10/82 50C 14-26