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APPL]CATION FOR PERMIT H SAN JOAQUIN LOCAL He4LTH DIS7RICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (204) 465-6781 DATE ISSUED is PERMIY 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. Loc 1 ealth Distri Job Address / Name a Owner's Name Address Contractor's Na E v- License No. Z 2-Z-4 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER (J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public L J Other Delta Type of Casing Irrigation Approx. Eastern Depth Specifications Cathodic Prosection . ❑Geophysical Depth of Grout Seal { Type of Grout U Other '• � _ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [ Well Diameter Sealing Material (top 50') _ Depth Filler Materia] (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is 1 Installation willserve: Residence _ Commercial _ Other available within 200 feet.) W Number of living units: _ Number of bedrooms Lot size p f Character of soil to a depth of 3 feet: 1-0 Arn Water table depth (Lj SEPTIC TANK Er/ Type/Mfg �R��. �� el^,, Capacity /;L UO No. Compartments VV PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal SEWAGE,SYSTEM Distance to nearest: WellSc; Foundation 1 Property Line / 00 t DESTRUCTION ❑ �t� w'^ , No`. & Length of lines L� 0 Total length/size �. LEACHING LINE U Z.2 p FILTER BED ❑ Distance to nearest: Well y /—foundation Property Line /Of) {-- SEEPAGE PITS L6 Depth _�.� size & Number SUMPS U Distance to nearest: well L rp t-Foundation jO�r Property Line 1120 -}- DISPOSAL PONDS �� n 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 persons subject to workman's compensation laws of California," The applican ust call 11 required inspections. Complete drawing o r erse side. }� Signed x a : Title: a Date:A) i, R DEPARTMENT USE ONLY �Appli . Accepted by Area [ Stk 466-6781 Additional Comments: " Lodi 369-3621 Pit or Grout InspectionXby Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies Environmenta Health Permit/Services 1601 H zelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. f INFO 43 3-s 3� J EH 13-24 REV. 10/82 10/82 500 14-26 ' F