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f ^ APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT G 1601 E. HAZELT,ON AVE., STOCKTON, CA PERMIT N U do Telephone (209) 46626781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 the San Joaquin Local Health District. �i© Ae.cT 5/ �A�y _„•_ Subdivision Name Job Address � ` Z,eAC'T IIIA 11_80 Owner's Name - Address Phone Contractor's Name OE44License,No. Phone j4S_-397/ TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION [J_' 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ' r J Industrial U Open Bottom �Manteca Dia. of Well Excavation Domestic/Private � U F-1 Gravel Pack Tracy Dia. of Well Casing -� 1-1 Public F-1 Other Delta A 9pprox. Eastern astern Irrigation Type of Casing F-I � Specifications Cathodic Protection Depth 5 p 17 Geophysical Depth of Grout Seal I !. U Other Type of Grout Surface Seal Installed by Repair Work DoneEl e of Pum _H.P. State Work Done t Well Destruction U Well Diameter Sealing Material (top 501) ' t Depth Filler Material (Below 501) REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sew TYPE OF SEPTIC WORK: NEW INSTALLATION T101er is available within 200 feet.) I `.Installation will serve: Residence _� Commercial Other Number"of living units: _� Number of bedrooms a2 Lot size 7 � i Char=acter of soil to a depth of 3 feet: - - dater table depth _ SEPTIC TANK, -'Type7Mf9-- '”" Capacity _J'LOO No. Compartments Z< r PKG. TREATMENT.,PLT. L] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM.. Distance to nearest: Well t?Q , Foundation /, z Property Line /� s DESTRUCTION f LEACHING LINE 'No. & Length of lines 3 ' Total length/size 12-6) )(2- FILTER 2- FILTER BED Distance to nearest: Well I O` Foundation 'Z-O Property Line , I SEEPAGE PITSDepth ��Ste_ Size a Number 3 � SUMPS E-I Distance to nearest: Well SO ' Foundation Q Property Line._ lie? DISPOSAL-PONDS a 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. �: 1. Home owner or licensed agent's signature certif-ies-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," r Contractor's hiring or sub-contracting signature certifies the•fa9-t$wing:-• -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 applicant must call for all required inspections. Complete drawing on reverse side. ° Signed_X� _ _ z:. t itle: Date: t FOR DEPARTMENT USE ONLY z Application Accepted by Area Stk 466-6781 Additional Comments: t �• �; Lodi 369-3621 F Pit or Grout Inspection7by i Date �S — Manteca 823-7104 Final Inspection by . Date rt/� L Tracy 835-6385 Applicant - Return all copies to: Env'r me al health Permi•t7Services 1601 E. Hazelton A�,E.-, P.O. Box 2009, Stk.1 CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED {.-RECEIVE,BY.d�' DATE` PE MIT NO., INFO