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APPLICATION FCZ PERPM;T SAN JCAQUIN LOCAL HEALTH OiSTRICT 1( 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 �p DATE ISSUED LLQ PERMIT EXPIRES I 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 Local Health District. �j 1 11 Job Address $Q Subdivision Name Owner's Nam Address 1 L._ O oAA Phone Contractor's Name �. C_. License No. �� Z��. Phone /W TYPE OF WELL./PUMP WORK: NEW WELL LJ WELL REPLACEMENT-.0' DESTRUCTION U W PUMP INSTALLATION SYSTEM REPAIR OTHER J 1 .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IndustrialU Open Bottom Manteca Dia, of Well Excavation • ; U Domestic/Private ❑ Gravel Pack D Tracy Dia. of Well Casing f Public Lj Other ❑ Delta -q Type of Casing LjIrrigation Approx. L] Eastern ' Cathodic Protection Depth Specifications Depth of Grout Seal I .� Geophysical Type of Grout, Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') 1 DepthFiller Material (Below 50') " v TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted" if ,public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other NN Number of living units: __]_ Number of bedrooms Lot size ,` Character of soil to depth of3 fee + 4 Q�.� -' Water table depth SEPTIC TANK Type/MfgJ _ apacity No. Compartments Z PKG. TREATMENT PLT. Type/Mfg Capacity Method of-Disposal I SEWAGE SYSTEM Distance to nearest: Well _ j r Foundation Property Line DESTRUCTION - - LEACHING LINE �i—J No. & Length of lines � k4 Total length/size o- 0Jcounty I FILTER BED Distance to nearest: Well �C7E� r Foundation I_ Property Line SEEPAGE PITS Depth Size d� Number 1 SUMPS L l Distance to nearest: well ISO -- Foundation Property Line $ __ DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu 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." r The applicant mu54 call for 11 required inspections. Complete drawing on reverse side. rr,, 4 3.Signed X a A A n Title: -uA Date: rX� FOR DEPARTMENT USE ONL Application Accepted by7* Area E] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection.A Date Manteca 823-7104 Final inspection by Date jL7 Tracy 835-6385 Applicant - Return all copi en o: . Envi onmtal Health Permit/Services 160 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �PERMITINFO A . �. Lh 13-24 REV, 10/82 10/82 500 14-26