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i , •_ APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT �3 15'8 1601 E. HAZELTON AVE., STOCK.TON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 7= ' PERMIT EXPIRES I 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 egulati ns kotheeg qu Local/.�Health District.Job Address caic� Subdivision Name �/ _. , Q1 Owner's Nam Address u Phone Contractor's Name License No. Phone&R, TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W 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 •❑ Industrials ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing ' ❑ Public [j Other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ' (J Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done ' Well Destruction,❑ Well Diameter Sealing Material (top 501) - Depth i Fi i l er*Meter ial (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR/ADDITION (J (No septic tank or seepage pit permitted.if public sewer is G7 available within 200 feet.) Installation will serve: Residence ✓ Commercial _ Other t Number of living units: Number of drooms 1- Lot size 4 Water table depth �7i Character of soil ,t.�o�Ia depth of 3 fe '`_ �- :1 SEPTIC TANK M Type/Mfg Capacity F-�"-�— Me• Compartments ' Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity SEWAGE SYSTEM Distance to;nearest: Well Foundation Property Line DESTRUCTION «- t LEACHING LINE ❑ No, 6 Length of lines "' Total` length/size III f-1FILTER BED Distance to nearest: Well Foundation L— Property Line SEEPAGE PITS Depth 9 Size - Number ,g.� SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' i hereby certify that 1 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. I, "I certify that in the performance of the work for which this Home owner or licensed agent's signature certifies the permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of Cali forn lac h Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whic this permit i ed, I shall ploy persons subject to workman's compensation laws of California." ' The appli t mu Call for 11 eq ctions. Complete drawing on reverse side. Signed 'v Title: ��""""1-h Date: OR ARTMENk,USE ONLY Area o.D Stk 466-6781 1 Application Accepted by �.�_ ❑ Lodi 369-3621 Additional CO, nts: Date �� ❑ Manteca 823-7104 Pit or Grout Inspection by A /r L7 Tracy 835.6385 Final Inspection by Date ' lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CR 95201 Applicant - Return all copies to: Environmental Hea FEE BASET!, OUE AMOUNT REMITTED RECEIVED BY DATEp y, Q,�ERM�ITQNO. INFO EH 13-24 REV. 10/82 10/82 500 14-26