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I APPLICATION FOR PERMIT k SAN JOAQLi" LOCAL H-FA.LTH D;STRdCT 1601 E. HAZELTON AVE., STOCKTONIhCA PERMIT NO, Telephore (209) 466-6781 4 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� (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 applicationjis 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 Joaquin Local Health District, Job Address lw-!��C. i�,.;:! [subdivision Name Owner's Name L. Address �/5'7P7� IFS r ,. >_, - Phone Contractor's Name J,&g - License No, 2 Phone y p7 y TYPE OF WELL/PUMP WORK: NEW WELL Q - WELL REPLACEMENT DESTRUCTION U p� PUMP INSTALLATION SYSTEM REPAIR OTHER U U, ` 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 IJ Industrial Open Bottom Manteca A. of Well Excavation Oomestic/Private Q Gravel Pack ❑ Tracy Dia. of Well Casing PublicOther Delta Type of Casing V Irrigation Depth Eastern pe epScifications .FICathodic Protection .:1 Depth of Grout Seal Geophysical Type of Grout _ U Other I Surface Seal Installed by w Repair Work Done ❑ Type of Pump N.P. State Work Done 0 P Wel] Destruction F] Well Qik yameter Sealing Material (top 5a4) _ , Depth it Filler Material (Below 50') TYPE OF SEPTIC WORK:. NEW INSTALLATION LJ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer' is available within 200 feet.) Installation will serve: :';Residence Commercial Other Number of living units: i Number of bedrooms _ 7 Lot size �J'Q 3t/3� ` i Character of soil to a depth of 3 feet: ! Water table depth SEPTIC TANK Li Type/Mfg Capacity No. Compartments �. Method of Qisposal PKG. TREATMENT PLT. Lf Type/Mfg Capahity SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ M M LEACHING LINE No. & Length of lines — L�O r f�. Total length/size. a.Ffc o , o-` ✓ r FILTER BED �, Distance to nearest: Well Foundation Property Line a4 SEEPAGE PITS Depth �.� Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line /0 DISPOSAL PONDS ❑ II !' µ i 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 rt permit is issued, I shall not employ any person in such manner as to become subject to worknan� 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 emplo ersons subject to workman's COUP)'lensation laws of California." The applica call _f t all re real i spections. Comple a dra i g�on reverse side. 40 Signed X ` Title: /f' ./L A,1 - Date: I!` FJA DEPARTMENT USE ONLYAre`i Stk 466-6781 Application Accepted by / I 34- Additional Comments' Lodi 369-3621 Pit or Grout Inspection by Date C/O-f-3 Manteca 823-7104 ` Final Inspection by, Date -io- d D Tracy 835-6385 hes to: . Environmental Health Permit/5ervicel' 1601 E. Hazelton Ave., P.O. Box 2009 tk., CA 95201 Applicant - Return all cop [FEE BASE AMOUNT DUE AMOUNT REMITTED .. RECEIVED BY QATE PERMIT ND.FO ,�- 3-t(S 1 10/82 500 EH 13-24 REV. 10/82 !I 14-26