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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. u Y3 Telephone (209) 466-6781_, .' . v=' DATE ISSUED G PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. r Job Address 5 O Subdivision Na o /� t' I Owner's Name ». Address © Contractor's Name ' s.�t� License No.. 2- Phone �l W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT OESTRUCTIDN PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION l AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS LN Industrial Lf Open Bottom Manteca t Dia. of Well Excavation Domestic/Priva.te,,�F_j Gra.ve1,.P_ack—....,.0 Tracy Dia..ofCWe1l Casing_ _ Public Other [] Delta Type of Casing . V Irrigation Approxi Eastern Specifications CathodicwProt eation - Depth of Grout Seal J Geophysical Type of Grout O U Other IkSurface Seal Installed by [ Repair Work gone G Type of Pump #'" H.P• k. "'. state Work Done - f - 9 } Well Destruction F� Well Diameter " Sealin Material (top 50'} b Depth Filler Material (Below 50') # i TYPE OF.SEPTIC WORK: NEW INSTALLATIONAIR . DDITION -LXJ (No septic tank or seepage pit permitted if public sewer is € available within 200 feet.) Installation will serve: Residence Commercial _ Other i r Number of living units: Number of bedrooms L - Lot size Character of soil to a depth of 3 feet: Water table depth _ 'jJj (,C' SEPTIC TANK YJ Type/Mfg �,�.- , r�Capacity o No.fCompartments� Z PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal '�SEWAG 'SYS�EN ci tante I' tonearest: 'Well �J�4 _Foundation s0 _ Property.Line S DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance'to nearest: Well Foundation Property Line SEEPAGE PITS ( Depth Z S� Size 1 Number ! SUMPS U Distance�to nearest: Well 1 o o Foundation n Property Line S 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 applica must cal o all required inspections. Complete drawing + j reverse'side. Signed X Title: [' Date: FOR DEPARTMENT USE ONLY El Stk 466-6781 App] tion Accepted by ' Area Additional Comments: ct Lodi 369-3621 Pit or Grout Inspection b Date _ LD Manteca 835-7104 Final Inspection by Date Tracy 835-6385 Applicant -.Return all copies o: EnviMntalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 i FFEEBASE AMOUNT DUE AMOUNTREMITTEDRECEIVED BY DATE PERMITN0. 11L ' 10/82 500 EH 13-24 REV. 10/82 14-26