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APPLICATION FOR PERMIT SAN JOAQbiN LOCAL HEALTH DISTRICT 1601 E. HAZEL.TON AVE., STOCKTON, CA PERMIT NO. �W 32- Telephone (209) 466-6781l DATE ISSUED T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. _7�J/� /Ya7JL� I � - — r Job Address C p� S �-i�n-Name kj; , Owner's Name Address Phone Contractor's Name2 �, �Q,� -_ License No. �'�� Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM-REPAIll OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ' OTHER'WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLFM'AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom [] Manteca - Dia. of Well Excavation �J Domestic/Private Gravel Pack' Tracy Dia., of Well Casing Public Other [] Delta !Type of Casing L Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal t ❑Geophysical -Type of Grout U Other `� , `, Surface Seal Installed by Repair Work,.Done Ej Type of Pump H:P3 state Work Done u Well Destruction U Well Diameter Sealing Material (top 50') ._ Depth Filler Material (Below 50') ({ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (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: —LNumber bo bedrooms `y Lot size Character of soil to a depth of 3 feet: Water table depth Ca achy f?<7d No. Compartments SEPTIC TANK i+ Type/Mfg P PKG. TREATMENT PLT. Type/Mfg 1 - Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well nVr.7 Foundation `Q Property Line /40 DESTRUCTION ❑ .. -- LEACHING LINE U No. & Length of lines Total length/size f FILTER BED LJ Distance to nearest: Well Foundation __/gg ° Property Line SEEPAGE PITS �j Depth f ! Size (f f Number �v SUMPS Ei-ro, Distance to nearest: Well Foundation _ F Property Line DISPOSAL PONDS I hereby certify-that -1 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: T 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 workmanK 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 ca for 1 required ins tions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted _-__ Area Q� �5tk 466-6781 Additional comments: i. L i�� fi9-3521 � ` p o *, --r�aut�nspection by Date Manteca 823-7104 Final Inspection by. `� Date !�g Tracy 835-6385 Applicant _ Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT ((REMITTED RECEIVED BY DATE p�REERMIT N0. INFO _ .� d l�'L � 1��-S•�� o`-T �'J�L 10/82 500 EH 13-24 REV, 10/82 14-26 V