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` APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. d�J 3— 35W Telephone (209) 466-6781/ y DATE ISSUED _5 PERMIT EXPIRES 1 YEAR FROM GATE 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 anndf Regula lt�i/p ns of theLSa/n Joaqu^ifn Local//},ilial th District. Job Address ,{ '-/y EAs /OJYL_ //ZQe ICM Subdivision Name �%�50fy � ' "�� ve i /S ` Owner's Name Address _,2,5-7L/t/ �. �Sa�,IG ��--_ Phone Contractor's Name / nOf7 v[ (;QL.[, License No. Phone O� W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ , PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE /(Vn" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom F-I Manteca Dia. of Well Excavation g Domestic/Private E3 Gravel Pack ❑Tracy Dia. of Well Casing Public Other Del to Type of Casing Li irrigation Approx. Eastern Specifications Cathodic Protection Depth n � Depth of Grout Seal Geophysical V Type of Grout Other Surface Seal Installed by L Repair Work Done El Type of Pump H.P. State Work Done LWell Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION �01 REPAIR/AODITION L_l (No septic tank or seepage pit permitted if public sewer is - available within 200 feet.) Installation will serve: Residence X_ Conmerciai _ Other Number of living units: —{fes— Number of bedrooms Lot size /66 ) W Character of soil to a depth of 3 feet:: Water table depth 4 SEPTIC TANK ❑- Type/Mfg PkP''CST Capacity 4200 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE — No. 8 Length of lines Total length/size /00 FILTER BED E] Distance to nearest: We1lOW 1p61 Foundation p/K/6I Property Line 5T77� ` SEEPAGE PITS Depth Size y Number / [ SUMPS Distance to nearest: WelldW._(6A/ Foundation 0-0 /QQ( Property Line J / DISPOSAL PONDS E3 _r7�- S ! S 41) /•-.Pa r� _�( w/ a r4,y� j a V I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ri 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 workmank compensation laws of California." 1 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 t call r all required inspections. Complete dreg on reverse side. Signed X Title: Date: L F DEP TMENT USE ONLY ❑ Application cep ed by i Area Stk 466-fi781 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 L Final Inspection by [f1r„ Date ay � /� ❑ Tracy 835-6385 ` Applicant - Return all copies to: Environmental Hea+6 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 LFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFOJ ^^^ [ / L EH 13-24 REV. 10182 p a 7� 10/82 500 14-26