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APPLICATION FO: PERM? SAN JOAQ1,1N LOCA_ n==.LTH DISTRICT [[[ 1601 E. HAIELTON :?1E., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 and Regulations of the San Joaqui nLocal Health District. iv :,P Address / /tom :,P & / ;, /�YI, Subdivision Name Owner's Name �[41 17 Address /o'/<i�" y f /e-j, /Z7,/ Phone Contractor's Name /= ,� l/%GiYli �n/y License No. _SW Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTIONF-1 PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p LJ Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation U Domestic/Private 0 Gravel Pack F-1 Tracy Dia. of Well Casing I:1 Public F-1 Other ❑ Delta Lt Type of Casing Irrigation Approx. Eastern fF-1CathodicProtection Depth Specifications Depth of Grout Seal 17 Geophysical Type of Grout U Other Surface Seal Installed by 4 Repair Work Done G 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 FG REPAIR/,ADDITION * (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) � Installation will serve: Residence L Commercial _ Other Number of living units: _Z_ Number of bedrooms 3 Lot size r; E Character of soil to a depth of 3 feet: '`1ii//�y J cyA�,•� Water table depth SEPTIC TANK Type/Mfg Capacity /,.tc"o No. Compartments ,7 PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation .20 ' Property Line /fie DESTRUCTION LEACHING LINE v No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well 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 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 workmans 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." Y The applicant mu G call for All required inspections. Complete drawing on reverse side. Signed X :/-i-. - !`LLFt Title: Date: :y � FOR DEPARTMENT USE ONLY Application Accepted by I',]I_ n,.r� Area Stk 466-fi781 additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date T Manteca 823-7104 Final inspection by ^ Date 7—)' Tracy 835-6385 Applicant - Return all copies to: ' vironmertal 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. k INFO 1J EH 13-24 REV. 10/82 10/82 500 14-26