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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HALLLTON AVE., STOCKTON, CA PERMIT NO. YJ! Telephone (209) 466-6781 �. �� 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 -^R/eg_ulati/oans of he n Joa uin Local H al h District. Joh Address,2E cls&0 ��-'tf Subdivision Name Owner's Nam@ C (.riL- -�� Address z;o Phone Contractor's Nam ' License No. ��Z _ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ° PUMP INSTALLATION [] SYSTEM REPAIR OTHER U 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 1J Industrial [J Open Bottom Manteca Dia, of Well Excavation U Domestic/Private F-1 Gravel Pack Tracy Dia, of Well Casing 17 Public [] Other E] Delta Type of Casing (71 irrigation Approx. Eastern F-1CathodicProtection Depth Specifications Depth of Grout Seal IJ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Q 1 Well Destruction ❑ Well Diameter . :Sealing Material (top 50') N Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is � available within 200 feet.) Installation will serve: esidence _ Commercial �' Other d Number of living unit Number of Adooms Lot size f1 CJLQ z�- r3S2 /�yy / Character of soil to a depth of.3 feet; `T Water table depthG� SEPTIC TANK Type/Mfg / Capacity No. Compartments PKG. TREATMENT PLT. .' Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM - pistance-to-nearest: Well �+� Foundation -/� Property Line, DESTRUCTION LEACHING LINE No. 8 Length of lines Total length/size yQ FILTER BED _17 Distance to nearest; Well (i` + Foundation _Zo /Property Line __ SEEPAGE PITS ff Depth Size �� " Number / SUMPS IJ Distance to nearest: Well /00"- Foundation /4J 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 in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to became 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." The appli,carK must cal for all required inspections. Complete drawing n verse side. C Signed x Title: Date: FO D PARTMENT [;"ONLY Ap ation Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection b Date L Tracy 835-6385 Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. Hazelton Av P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO d � / 1 EH 13-24 REV. 10/82 10/82 500 14-26