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i APPLICATION FOR PERMIT SAN JGAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��[1i-S Telephone (209) 466-6181 . 5 ? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GATE ISSUED -kLL (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 ItIhe Rules and Regulations of the San Joaquin Local Health District. Job iddress `.� 1'e Subdivision Name Owners Name 4 Address ^S PhonejF(' f(] 11 Contractor's Name License No. (�l Phone TYPEIOF WELL/PUMP 14ORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER — Li DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (71 in U Open Bottom ❑ Manteca pia, of Well Excavation L_I Domestic/Private Ej Gravel Pack ❑ Tracy Dia. of Well Casing Public �j Other Delta I ,, 3� Type of Casing 1 V Ilrigation Approx. Eastern; . Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal OtherType of Grout Surface Seal Installed by Repan Work Done FJ Type of Pump.—H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') et/LA(ED epth' � ,�t+n-, y 1 Filler Material (Below 50') -rf l j� -- TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is V available within 200 feet,) Installation will serve: Residence Commercial Other Nu ber of living units: _� Number of bedrooms Lot size 5 Character of soil to a depth of 3 feet: + -------�----,. Water,table depth i SEPTIC TANK CJ Type/Mfg li"x�r # Capacity �No.,,Compartme`nts i PKG. TREATMENT PLT. ❑ Type/Mfg ; } .a� Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well{( L.._,___Eoundation Property Line x ,DESTRUCTION 4 ' LEACHING LINE 'No, & Length of lines" + "t r Total-3.en th/sfze 40 i FILTER BED -` Distance to nearest: Well t )' �oundation'1'7 EQ Property Line 'T 2-M/ SEEPAIGE PITS Depth As( Size 5(41C dt&- t :Number 4,'.. ` SUMPS L-1 Distance to nearest: Well I SIDI/ Foundation Property Line ? DISPOSAL PONDS _ ' ' 1 I hereby certify that I have prepared this application and thaf`the work will be done in accordance with San Joaquin cdunty ordinances, state laws, and rules and regulations of the`$an,Joaquin Local Health District. Home owner ar 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 workmanK 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 persons subject to workman's compensation laws of California." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed X L S Title: u) Date: �' DEPARTM T USE ONLY r�L Application Accepted by Area v� Stk 466-6781 Additional Comments:, Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 Final Inspection by Date ) ❑ Tracy 835-6385 Applicant - Return all copies to: . Environ tal Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 a FEE `BASEAMOUNT DUE x'_r AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/8210/82 500 14-26 -- `'1�o sr�