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APPLICATION FOR PERMIT SAN JOAQU2LOCAL-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 t GATE ISSUED -- 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 JoaquinLocal Health District. Job Address 7i. 5 / 4. •.4 ,4>Subdivision Name Owner's Name / i+1•� Address' s Phone t , Cont Name Z4,�._.r,M1 License No. 77 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F_� DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES .,JI -i _ DISPOSAL FLO. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA I_Jlndustrial [j Open Bottom ❑ Manteca Domestic/Private k Gravel Pack D Tracy CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation % �- Oia. of well Casing 15 Public Other Delta Type of Casing E;rZZr Z V Irrigation Z Z S Approx. Eastern Specifications 10 G Cathodic Protection Depth Depth of Grout Seal ..__ 5: Geophysical Type of Grout .&ey n LV- LT other Surface Seal Installed'by % L% Repair Work Done ❑ Type of Pump S H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (8elow,50') TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION ❑ (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: Other Lot size SEPTIC TANK LI Type/Mfg Capacity PKG, TREATMENT PLT. ❑ Type/Mfg Capacity SEWAGE SYSTEM Distance to nearest: Well Foundation _ DESTRUCTION Q LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Water table depth No. Compartments _ Method of Disposal Property Line Total length/size � Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS -Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have preparedthisapplication 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, { Homeowner 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 persons subject to workman's compensation laws of California." The applicant must call for a 1 required inspections. Complete drawing on reverse side. y Date: Title: Signed X 1�,ct�6 FOR ENT USELY � Z� � Stk 466-6781 Application Accepted by Area Lodi 369-3621 Additional Comments: S�.eo�� Pit or ( .Aspection by D e Manteca 823-7104 Final Inspection by Date NN ❑ Tracy 835-6385 Applicant - Return all copies.to: Envir ental Health Permit/Services 1601 E. Hazeltonl7rve., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED INFO I EH 13-24 REV. 10/82 14-26 RECEIVED BY DATE I PERMIT NO. -Sr _1 1-7 1, C• *__ 10/82 500