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(09) APPLICATION FOR PERMIT 6LL®V® P. [BEGHTEL SAN JOAQL;N LOCAL HEALTH DISTRICT LILLIAN M. B E G HT E` 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. *1 84 2 7UXEDO AVE. Telephone (209) 466-6781 S TOC CTO Na CA 95204 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 nd the Ru ;,and Regulations of the San Jo quin Local Health District. Job Address (/ /�- Subdivision Name Owner's Name dress Phone1_q" Contractor's Name A- Irkte License No. Phone YPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT E] DESTRUCTION LJ 0i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINFS-Td S e we 1-DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation _ }_} Domest-is/Priva.te- - Gravel Pack - Trac — —_— -- Diaw-of-We1H -Casin - ❑ Public E-1 Other Delta T Irrigation Type of Casing L 9 Approx. L] Eastern Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal (�Other Type of Grout Surface Seal Installed by Repair Work Done FJ Type of Pump H.P. State Work Done well Destruction U well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM1wrDistance to nearest: Well Foundation Property Line DESTRUCTION ` LEACHING LINE ❑ No. & Length of lines Total length/size �J FILTER BED Distance to nearest: Well Foundation Property Line n SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 it 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 workmanK 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." XThe appli must ca 1 fqX al} wired 'ns c ons, Complete ding on reverse side. e� Signed X �d Title: 11 (fe} (� 'C�_� Date: (j Fit DEPARTMENT USE ONLY �+ Application Accepted by (" Area �j Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by �//� Date r9 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 NO. INFO f EH 13-24 REV. 10/82 10/82 500 14-26 f;.