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Y � APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 ETelephLTONne jAVE., STOCKTO�N, CA PERMIT NO. �.. DATE ISSUED g 263 So. Of,) StO.�ton, Caiif. 9�205s = H PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'ten OliifllOtOl 5 L�Ic.#Zfi�l� � r PiI.T� ' (Complete in Triplicate) Application is hereby-made to the Sari 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 Re Mations of th San Joaquin Local Health District. , �AG��I�"�4 �f Job Address00 Srbdivision Name . �f Owner's Name dressaa, mxt"pnone Contractor's Name License No, Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR 17 OTHER i DISTANCE TO NEAREST: SEPTIC TANK SEWER.-LINES DISPOSAL FLO. PROP. LINE t AGRICULTURE WELL WELL PITS/SUMPS FOUNDATION OTHER � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 17 Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack_ Tracy Dia.. of Well Casing S Public Other Delta Type of Casing L Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal E]Geophysical Type of Grout U Other Surface Seal Installed by r Repair Work Done G Type of Pump H.P, State Work Done Well Destruction U Well Diameter Sealing Material (top 501) — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other41 # Number of living units: -.� N]feet: ber of bedrooms Lot size �. Character of soil to a depth of 3 Water table depth SEPTIC TANK Type/Mfg ' apacity o. Compartments ry t Capacity Method of Disposal. PKG. TREATMENT PUT. - Type/Mfg r SEWAGE SYSTEM. Distance to.nearest: Well Foundation Property Line - DESTRUCTION LEACHING LINE No. & Length of lines Total length/size Pro pert Line FILTER BED ' Distance to nearest: Well Foundation �� y � j .�- Number '� SEEPAGE PIT-S-' Size - kkk r +Foundations rPropertylLine �Q 3 SUMPS �^ �� Dis;t.pnce to-nearest: welI 4W-61', � :o-� DISPOSAL PONDS -i I hereby certify that I havprepared this application and that the work will be'done in accordance with San Joaquin county e ordinances, state laws, and rulesxand regulations of the-San,Joaquin Local Heal h'District. �. ' 1-a Home owner or licensed agents signature cert_-_ifies tthhe,.followingc� I .certify that-,in the performance of the_work for which this permit is issued, I shall not em'phoy any person �n'such manner`as to become subject to workman compensation laws of California." Y Contractor's hiring or sub-contracting signature certifies the followings"I certify that in the performance-of the work for which .e this permit is issued, IYshall employ persons subject to workman's compensation laws of California." applicant for all required spec ' ns. Complete drawi g on a 'se side 7 The app } Date: � ` `PA 5 rai ` Signed X Title: f R ARTM USE ONLY Area, �� 5tk - 4fib-fi781 Application Accepted by _ ❑ Lodi 369-3621 Additional Comments: Dl�Manteca 823-7104 Pit or Grout Inspection by Date Final Inspection by Date /� '- 3 j[D Tracy` $35-63$5 s Applicant f Return all copie o: Environmental ealth Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 µ.. PERMIT N0. FEE'` BASE A T DUE AMOUNT REMITTED RECEIVED BY DATE INFO .1 5r 9 —1 —�3 S 10/$2 500 � EH 13-24 REV. 10/82 - 14-26