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APPLICATION FOR PER;ii T SAN JOAQUiN LOCA! H1 ?LTs DISTRICT 1601 E. HALELTON AVE„ STOCKTON, CA PERMIT No. Telephone (209) 466-6781 � ^g� DATE [55UE0 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 a.Rd Regulations of the`San Joaquin Local Health District. Job Address / 2 i141- /167; 7 4 Subdiiv`i,ion Name din' ( / p Owner's Name .%L, s 122'.04k:2 //Address (®� � pec lions Contractor's Name i License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION U s PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK 7 3[7tj SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `fi^ INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial U Open Bottom [ Manteca Dia. of Well Excavation ` Domestic/Private Gra vel aPack ❑ Tracy Dia. of Well Casing 17 Public [j Other Delta Type of Casing El Irrigation Approx. Eastern El Cathodic Protection Depth Specifications Geophysical Depth of Grout�Seal U Other � Type of Grout � Surface Seal Installed by Repair Work Done Type of Pump J H.P. State Work Done Well Destruction U Well Diameter .' Sealing Material (top 50') _ Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg ` Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION 1 LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS F-1 Depth Size Number - I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 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 permit is issued, I shall not employ any person in such manner as to become subject to workmanR 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 iss ed, I,shall e play persons subject to workman's compensation laws of California." The appl Ca st tall or 1 required inspections. Complete dr f�C/Jon reverse side. Signed X Title: _ Date: 04i ARTMENT SE ONLY Application Accepted by Area -Y ❑ Stk 466-6781 Additional Comments: .Lodi 369-3621 Pit or Grout Inspection by. Date Ll Manteca 823-7104 Final Inspection by Date - /1' L Tracy 835-6385 Applicant - Return all copies to: . Eni nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFOCA_ J EH 13-24 REV. 10/82 10/82 500 14-26