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APPLICATION FOR PERMIT u SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA _ PERMIT NO. Telephone (Z09) 466-6781 - DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED la (Complete in Triplicate) t 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 Joaquin cal Health District. Job Address -3,6�` Subdivision Named a✓ .'P �gT- S _�41 Owner's Name 1AA Addre s Phone _ Contractor's License No, S -22!57Z2. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT 'DESTRUCTION I PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ ` DISi•ANCE TO NEAREST: SEPTIC TANK d1 SEWER LIiNES DISPOSAL FLO. PROP. LINE V FOUNDATION AGRICULTURE WELL -� OTHER WELL PITS/SUMPS y_ 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation L.1 Domestic/Private ❑Gravel Pack C Tracy I Dia. of Well Casing (' 0Public �J Other Delta r Type of Casing U Irrigation Approx. Eastern TjL ` Specifications E]Cathodic Protection :Depth _ FJ Geophysical ; Depth of Grout Seal Type of Grout LJ Other Surface Seal Installed by RepalrWorF-Oofie�-"-Ty"pe'of�'Pu'mpr"" -� .._......N.� State Work Done Well'Oestruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION (J (No septic tank or seepage pit permittee! if public sewer is available within 200 feet.) Installation will serve: Residence _./ Commercial _ Other 9 i Number of,"1"iv"ingunits:'-T'I'Number 6f-bedrooms Lot size l C4aracter.of soil to a:depth of, 3-Ifeet• Dp cam. Water table depth SEPTIC TANK _+ Type/Mfg / L M_,Ca`pacvty,',. 16e"d No. Compartments PKG: TREATMENTI PLT. ]��'Type/Mfg j i ^_Capacity�l�r�p-O•- "ethod of Disposal GE SYSTEM SEWAGE ! t I �~�Ui:Stan4e to nearest: Well 1�- Foundation'��operty Line DESTRUCTION -- i LEACHING LINE No. & Length of lines "�lJ > 'Total length/size - f1LTER BED `] Distance to nearest: We1a r Foundation Y Property Line 'rSEFP.AGE PITS F-1 Depth Size Number .SUMPS IJ Distance to nearest: i1MI Foundation Property Line r,/DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with;San Joaquin county r 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 workman t 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 a ubject„to,workman;s.-compensation laws of California. The applicant must ca f 1 rf.Uired inspections'_ Complete,.3drawing on reverse side, p_ Signed XTitle .i,/Lss�.-esrC i Date: F R DEPARTMENT,USE,ONLY,.,,...-.___ I Application Accepted by IIA Area 14D Stk 466-6781 Additional Comments: , _ ( ~`.. i (j Lodi 369-3621 Pit or Grout Inspection by�i '^~ Date ; ' Manteca 823-7104 Final Inspection by � - __ Date , Tracy; 835-6385 Appliicant - Return all copies to: � Environmental' Health Permit/Services 1601 E. Hazelton Ave., P_0. Box 2009, Stk., CA 95201 S FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY j DATE— PERMIT NO. i INFO �- EH 13-24 REV. 10/82 II -� 1 1 10/82 500 14-26