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APPLICATION FOR PERMIT S4N JOAQLiIl LOCAL HEALTH DISTRICT X 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Y3 (� Telephone (209) 466-6761 o r �,5 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 Joaquin Local Health District. Job Address / Subdivision Name 9/577 c1 'Owner's Name /7 Address / � [jr1. Phone Contractor's Name , License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑1 DISTANCE To NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 I❑ industrial ❑ Open Bottom ❑ Manteca Dia. of. Well Excavation f Domestic/Private ❑Gravel pack ❑ Tracy Dia. of Well Casing !3 ❑ Public ❑ Other ❑ Delta Type of Casing Li Irrigation Approx. ❑ Eastern LJ Cathodic,Protectin Depth Specifications �,,.,�.-_ f _ �„_ E] o - - OepthTof-Grout�Seal ❑Geophysical=;- :�,.----r Type of Grout Other Surface Seal Installed by Repair Work Done ❑- Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLAT16-N ❑I REPAIR/ADDITION I (No septic tank or seepage pit permitted if public sewer is avai)able within 200 feet.) _Y . . '. Installation will serve,:. Residence Commercial _ Others - Y-- S Number of living units: 32 Number of bedrooms Lot size Character of soil to a depth of 3 feet: f Water table depth Zo SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments w PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Wei'] / foundation - ,!�+_ Property Line 9 DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number Z111— SUMPS ❑l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ T 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 workmang compensation laws of California." I' \ 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." The applicant st call for all - red inspections. Complete drawing on reverse side. 9 _ r Signed X Title: < Date: FOR DEPARTMENT USE ONLY Application Accepted by Area � �__ ❑ Stk 466-6781 Lodi 369-3621 Additional Comments: Pit or Grout Inspection Date ❑ Manteca 823-1104 Final Inspection by Date �0 ❑ Tracy 835-6385 Applicant - Return all copies to. Environmental Health Permit/Services 16 E. azelton Ave., P.O. box 2009, Stk., CA 95201 } FEE BASE AMOUNT DUE M AMOUNT REMITTED RECEIVED BY DATE 22 PERMIT NOT. INFO � ��— 1,30 10/82 500 EH 13-24 REV. 10/82 ff 14-26