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APPLICATION FOR PERMIT SAN JOAQU'iN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED, f�-.,j,.(Complete in Tripl icate) 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 RuleW . R uiatio f S n Joaquin Local Health District, ,. j Job Address t.. � Subdivision Name 1 SVI / Owner's Name .� Address t1� �/A Phone f Contractor's Name c 1��L License No. Phone 3 74 ETYPE OF WELL/PUMP WORK; NEW WELL WELL REPLACEMENT DESTRUCTION ❑ O� PUMP INSTALLATION ( SYSTEMI REPAIR OTHER U W ` DISTANCE TO'NEAREST: SEPTIC TANK 'l�� SEWER LINES / r '' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - tJ I_J Industrial V - U peniBottom [] Manteca Dia, of Well Excavation L UT o P_ 4Public Domestic/Private ravel Pack F7 T acy Dia.- of Well Casing= Irrigation El elta _ Type of Casing G L o C V 9 Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical r Type of Grout [JOther 1 ~ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 50') _ Depth filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION �I J (No septic tank or seepage pitpermittedif public sewer is } ( — available within 200 feet.) Installation will serve: 1Residence Commercial Other_ z Number of living units: Number of bedrooms Lot size + ! E Character of soil to a depth of 3 feet: Water table depth i SEPTIC,TANK 'Ej Type/Mfgl{ Capacity No. Compartments I , PKG. TREATMENT PLT. Type/Mfg f Capacity Method of Disposal �`• + SEWAGE SYSTEM .Distanceffflllto nearest- Well Foundation Property Line DESTRUCTION ❑ ro LEACHING LINE U No. & Length of lines t e Total length/size ! �f FILTER BED Distance,to nearest: Well Foundation Property Line SEEPAGE PITS f-I Depth Size Number y z SUMPS L Distane!e`to nearest:.- Well Foundation Property Line DISPOSAL PONDS ❑ t 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, 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 t 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 shall employ persons subject to workman's compensation laws of California,". r The appli n mu a 1 1 r fired inspections. Complete dr M reverse side, Signed X 1 Title: Date: 1/4 1IR 3 �p I FOR PARTMENT USE ONLY t �I Application Accepted by Area " _ _ Stk 456-6781 �Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Ar+rly5/(y, 4/tei, 710 T1 to ` Manteca 823-7104 1 Firal Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: qnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O Box 2009, Stk., CA 9520I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Li 0-1 EH 13-24 REV. 10/82 ry ' - - - 10/82 500 14-26