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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 160i E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 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 Regulations of W gydh ,#tl Health District. Job Address /9✓�� 11^/,41v/v Subdivision Name Owner's Name �/jA1p/ �tEVO Address //�'� HpWeY- C _P,46,'O:E 60411 Phone y6,�-art 69 ��/ Contractor's Name 9e_150N License No. Phone _5;23- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial U Open Bottom [}Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public [-10ther Delta Type of Casing Irrigation _ '^ App�ox. Eastern Specifications Cathodic.Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout [j-Other Surface Seal Installed by V1 Repair Work Done E] Type of Pump H.P. State Work Done � Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L71 REPAIR/ADDITION j (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: f Number of bedrooms `/ Lot size 11—AC TC Character of soil to a depth of 3 feet: C4 M L4.9Water table depth SEPTIC TANK Type/Mfg pYe G S f G o NC• Capacity ! G 00 No. Compartments R PKG. TREATMENT PLT. [j Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well to' Foundation / '/' Property Line DESTRUCTION LEACHING LINE ❑ No. &'Length of lines Total length/size M FILTER BED Distance to nearest: Well $6� Foundation x P Property Line SEEPAGE PITS [j Depth Size Number SUMPS ❑} Distance to nearest: Well 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 Joaquili 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 permit is issued, I shall not employ any person in such manner as to become subject to workmarK 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: �- 3.0-cf„y FOR PARTMENT llSE ONLY Stk 466-6781 Application Accepted by �, ,`ti y _ Area ❑ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by n Date �' Tracy 835-6385 Applicant - Return all copies to: Environ me t He th Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ' 10/82 500 EH 13-24 REV. 10/82 14-26