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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO, r! L9 Telephone (209) 466-6781 QQ DATE ISSUED PERMIT EXPIRES 1 YEAR FRCM 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. 1B62 for wel3/pump and the Rules and Regulatiggs of the San Joaquin Local Health District. 'Job Address��f �,. 41QIA ,e.[ Subdivision 'Name Owner's Name t Address 6FJ-0-7 Phone Contractor's Name Ll-ense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Oper Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack U Tracy Dia. of Well Casing Public CjOther ❑ Delta r Type of Casing U 71Irrigation Approx. El Eastern Depth Specifications Cathodic Protection Depth of Grout Seal 1-1 Geophysical Type of Grout fT FD Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') �fn1 Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTAL REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other S Number of living units: 1 Number of bedrooms Lot size A C2 Character of soil to a depth of 3 feet: Water table depth CZ3110 SEPTIC TANK [ Type/Mfg eaLl& Capacity 1&P n No. Compartments PKG. TREATMENT PLT. Type/Mfg / �� Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 50 [.r Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines 13 L4L' Total length/size - A -'.- LJ FILTER BED ❑ Distance to nearest: well _ FoundatrioLn� _ Property Line SEEPAGE PITS ❑ Depth Size � ��-.r Number :;2- SUMPS T Distance to nearest: Well 1 042 U—foundation 10 Property Line DISPOSAL. PONDS ❑ 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 workman 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 subject to workman's compensation laws of California." The applican ust call for al e�quiired inspections. Complete drawing on reverse side. 9 r J Signed X V"U�C� c(L, Title: Date: '1"'I�^q �— DEPARTMENT USE NLY Application Accepted by Area — Q-.-Stk. 466-6781_ M Additional Comments: ,l Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 Final Inspection by Date + ❑ Tracy 835-6385 Applicant - Return all copies to: Environments Health Permit/Services 1601 E_ Hazelton A P.O. Box 2009, Stk., CA 95201 FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO s EH 13-24 REV. 10/82 10/82 500 14-26