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I APPLICAT[ON. FOR PERMIT r SAN JOAQUiN LOCAL HEALTH DISTRICT �Q j ,. 1501 E. HAZELTON AVE., $TOCKTON, CA PERMIT NO. Telephone (209) 466-6781 t DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Ji n 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 r and the Rules and Re ulations of the San Joaquin Local Health District.. Job Address p� -^ P—et Subdivision Name Owner's Name (J J J,p 4, -Address Phone #tet - Contractor's Name ?fide f)eA(17(n JD License No. 6 79 Phone TYPE OF WELL/PUMP WORK: ' NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTICITANK SEWER LINES DISPOSAL FLO. PROP. LINE w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CDNSTRUCTION SPECIFICATIONS T _ J Industrial U Open Bottom F-1MantecaDia, of well Excavation 1J Domestic/Private F-1 Gravel Pack 0 Tracy Dia: of Well Casing oil 17 Public [—I Other ❑ Delta ` Type of Casing F', Irrigation II Approx. E] Eastern [Cathodic Protection Depth Specifications + 1 Depth of Grout Seal Geophysical U Other Type of Grout Surface Seal Installed by Repair work Done El Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth ''i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION U '(No septic tank or seepage pit permitted if public sewer is v 1 I # available within 200 feet.) Installation wi.11 serve: Residence Commercial Other Number of living units: �� Numbe"r of bedrooms -Lot size Character of soil to a depth of 3 feet: Water table depth .. SEPTIC TANK Type/Mfg0.1 �� Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Cis offal SEWAGE SYSTEM ot--� Distance to nearest: Well U��,l ndation Property Line DESTRUCTION �-I i, LEACHING LINE No. & Length of lines Total length/size v4 FILTER BED DFistance tb,nearest; Well Foundation Property Line --E.- SEEPAGE PITS rt�' Depth Size 3 e3 Number SUMPS U Distance to nearest: Well Foundation Property Line . DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will he 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 thisk permit is issued, I shall not employ any person in such manner as to become subject to workmant 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 compensati.on.,l.aws .of California." The applicant mus all for,all wired inspecti s. Complete drawing on reverse side: Signed X IP Title: ��/ Date: USE ONLY Application Accepted by : Area , Qz Stk 466-678 . Additional Comments:' - El-Lodi - '1 369-3621 �- ' Pit or Grout Inspection by Date Manteca 823-7104 1/ Final Inspection by: Date �3-�-� L Tracy 835-6385 .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 EH 13-24 REV. 10/82 10/82 500 14-26 a