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APPLICATION FOR PERN,1T F SEPI JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT Np. �I ^Lf F Telephone (209) .466_6781 PERMIT EXPIRES I YEAR FROM DATE ISSUEQ DATE ISSUED _ c{ (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 . ) - S_. ' Subdivision Name � - Owner's .Namet - �tA✓>�� Address L �.�-1� Phone Contractor's Name p�= License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [�- CESTRUCTION,�� PUMP INSTALLATION f❑ SYSTEM REPAIR ❑ OTHER::'U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ( Industrial U Open Bottom Manteca �� ❑ Dia. of Well Excavation r LJ Domestic/Private M. ❑ GravelrPaek ,a''❑ Tracy Dia, of Well Casing 17.Public ' [j Other ❑'Del to i1rr.igation. JType of Casing Approx. _❑Eastern Cathodic Protection Depth - -- -Specifications (❑ Geophysical _ Depth of Grout Seal U 0ther Rf� Type of Grout ` I , x Surface seal Installed by Repair Work Done ❑ Type of Pump H.P. -State-Work Done, .- Well Destruction F_1 ' Well Diameter Sealing Material '(top 501) 1�1 ' s Depth P Filler Material (Below :80'} • + �+ i ---`TYPE-OF SEPT°I�` WflRa�:{-fifCtd Ih1STL4ILdJ� i2fPA[R;40DiT.I@N s r c `ti; •- N �� IJ ! J-(-No-septic"tank-flr. eepaje-pit=permit-t-ed if,publ-ic-sewer-Lis--- I sewer-is-- R. available wit'hi'n 200 feet.) Installation will serve, ' 'Residence Commercial"•-"'✓`..Other Number of living units: Number of bedrooms Lot Size Character of soil to a dep h of 3 feet: a S4 ,r, i = Water table depth SEPTIC, TANK Type/Mfg Capat ify Arm No. Compartments t PKG. TREATMENT PLT. Type/Mfg P Ca 'city ~- ---— Method of Disposal SEWAGE SYSTEMDistance ' :1 — to nearest:_ ..Well Found tion Pro ert Line y, DESTRUCTION L_1 a p ys . _ LEACHING LINE u No. &. Length of lines I Total length/size ' J FILTER BED P0 Distance to nearest: Well Foundation Property Line _71T j SEEPAGE PITS Cj Depth Size _ Number i .SUMPS �� Distance to, irearest-,,Wel-1 '-Foundation Property Line x DISPOSAL PONDS ❑� [ - I hereby certify that I have prepared this application ana 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 agept'-s,signature certifies the following-,"I'certify that in the performance of the work for which this x. permit is issued, I shall not employ any person in such manner as to.become subject to workman$ compensation: laws of California." i. Contractor's' hiring or sub-contracting signature certifjes the following; "I certify that in the performance of the work for which i` this permitlis issued, I shall employ persons subject to workman's campensation laws of California." I .., The applicant-must cf a'l'l- o,r al'1"'req iced .inspections. CampleW,dravring on reverse side. Signed X R" Title: (r:!f�� _ _ Date:4. '3r F EPARTIIENT USE ONLY Application Accepted by !11Area 4� Stk 466=6781 Additional Comments: [� Lodi 369-3621 } a I Pit or Grout Inspection Date Manteca 823=7104 � Final Inspection by r Date Tracy 835'6385 9 Applicant - Return; all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO �7 `f .w EHx13-24 REV' EV10/82 fir - - �- +. :. .. .10/82! 500 14-26 . r