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APPLICATION FOR ?Efi'rAiT J SAN JOAQUi% LOCAL H;ALT4 DISTRICT +Q /� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 3- (e65 Telephone (209) 466-6781 pp� w. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED b G (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 incomplian a with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welt/pump and the Rules andRegulationstof he San�10 9u oc Health District, Job Addres1-�rl `if Jy,i� Subdivision Name r Ommer's Name Zktf 64h`P.�.,1Q,L..�-f t/�� Address �1 �t phone 7Q��-f�S'a7-V Q Contractor's Nam �pa�w/xI�O�Al( '(A License No. ` IX Phone`�p -501-15, TYPE OF WELL/PUMP WDRK: NEW WELL' WELL REPLACEMENT DESTRUCTION ❑ r. PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U W DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL fLO. PROP. LINE 6' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IC r. V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial U Open Bottom [:]Manteca Dia. of Well Excavation LJ Domestic/Private ❑Gravel Pack EJ Tracy Dia. of Well Casing Public ❑Other E]Delta Type of Casing Lj Irrigation Approx. E]Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal insta it ed by Repair Work Done ❑ Type of Pump H.P. State Work Done •� Well Destruction Lf Well Diameter Sealing Material (top 50') - ➢` Depth Filler Material (Below 50') � TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION C-f'�(No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence '/Comnerc ial Other Number of living units: Number of b roo J Lot size / Character of soil to a depth of 3/feet : Water table depth Q w. SEPTIC TANK Type/Mfg 1 M capacity D No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposjl SEWAGE SYSTEMci Distance to nearest: Well y� Foundation DESTRUCTION Property.L ane _ �t S LEACHING LINE No:- b Length of lines Totlength/size pr `rAU;{•. FILTER BED C] Distance to nearest: Well 'ayi�_ Foundation Al/— Property Line I,):- SEEPAGE PITS Depth Size Number 3 ! SUMPS l_.j Distance to nearest: Well =rpo r Foundation �_ ,� 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`fallowing: "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." The applicant m ca 11 f all equired inspections- Complete drawing gn verse side. Signed X Title: v.l, Date:ad" � FOR DEPARTMENT USE ONLY Applicat Accepted by /yt Area Stk 466-6781 Additional Comments: Jq Lodi 369-3621 Pit or Grout Inspection b Bate ❑ Manteca 823-7104 ` Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o: Enviro mental Health Permit/Services 1601 E. Ra elton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE 1 AMOUNT REMITTED RECEIVED BY / DATE PERMIT NO. INFO 4f 4,5I 6 eZ7 -7�J3 a 3-LOOS w. EN 13-24 REV. 10/82 10/82 500 14-26