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APPLICATION R , ERMI i SAN JOAQUltl L AL HEATH 'DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6181 DATE 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 Jo qyi Local Health District. + T �_ y F Job Address G�3 to 22 pY' 0 ` Subdivision Name l�Tl P1'U �e T117 3"z a/ r��- � k_ Owner's Name � Address T�� '/aC- S e S2 Phone �JS1/� 60p�0 Contractor's Name �- , +"� h� License No. og 5-6Z Phone _3S/ 609, TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LI- ul) DISTANCE TO NEAREST: SEPTiChTANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 s r .-FOUNDA`ION AGRICULTURE WELL OTHER WELL PITS/SUMPS P INTENDED USE iNTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y Industrial El Open Bottom [] Manteca Dia. of Well Excavation ^, U Domestic/Private P Gravel Pack [� Tracy Dia, of Wall Casing a Public [j Other Delta Type of Casing Irrigation I� Approx. EJ Eastern Depth €Specifications �� t �S Cathodic Protection p Depth of Grout Seal 9 US Geophysical Type of Grout U Other Surface Seal Installed by x � Repair Work Dane Type of Pump H.P. State Work Done k Well Destruction U Well Diameter Sealing Material (top 50') Depth` Filler Material+(Below 50'") TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION (No septic tank o r�-seepage pit permitted if public sewer is l available within 200 feet.) Installation will serve;! Residence _ Commercial. [ Other , Number of living units: Number of bedrooms ' ; . Lot size _ r "r Character of soil to a depth of 3 feet: ' Water table depth S / E SEPTIC TANK Type/Mfg Capacity /�Q O No. Compartments i` PKG. TREATMENT PLT. J Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM istance to nearest: Well Foundation Property Line DESTRUCTION � .IM. r ' '- � , r z Total length/size 6 0 f LEACHING LINE No, & Length of lines FILTER BED Distance to nearest: Well Foundation Property tine. r SEEPAGE PITS Depth Size Number .SUMPS L-1 yDistance to nearest: Well. + Foundation Property Line DISPOSAL PONDS ❑ f I 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, ani rules and regulations of the San Joaquin Local Health District, !i 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 workmant compensation laws of California." Contractor's hiring or subs-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 four all required in pections.l Complete drawing on reverse side. ?� Signed X F f� l Title: VDate: i FOR D ARTMENT USE ONLY Application Accepted by _ Area Stk 466-6781 M — - Lodi 369-3621 J^ -- Additional co _ _ Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date /P/ �� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. INFO 49- J� EH 13-24 RFV. 10/82 10/82 500 14-26