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APPLICATION FOR PERMIT CLAR'E'r''dC,_'S SEPTIC & ScVJER SEP11r.E SAN JOAQUIN LOCAL HEALTH DISTRICT H'3 S7- 01'0 1�- S ockton, Calif. 95205 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 2 0 q C[J�;_rar.,•3Cs Lic,X2':,7177 Telephone (209) 466-6781 DATE ISSUED 7 �1 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 and- Regulations ge 5 oaquin ocal lth District. Job Address Subdivision Name Owner's Name I Address Phone Contractors Name License No. Phone44 �! TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other ] Delta ^� IJ Irrigation Approx. Eastern Type of Casing De th Specifications Cathodic Protection P Depth of Grout Seal 1-1 Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE F SEPTIC WOO K NEW Tj�STALLATION REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is 1406 al il��e�Res� ce Commercial Other available within 200 feet.) IX Number of living units: _/_ Number of bedroo e Lot size f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity /��c �i4L. No. Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line a � ,� o LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well � FoundationProperty Line " TT SEEPAGE PITS Depth Size Number _ SUMPS U Distance to nearest: Well Foundation ZZ" 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 applicantpuit c 1 for all required, ' specti s. Complete dra p , uerss.$.i e. l` PP,Cr � ,ti'II� SEWER SERVICE Signed X Title: _ ,., �_ n _ o� n i:� ncnne Date: ram-g�aekton, Garr:--laze A OR DEPARTMENT USE ONLY Py, ^i.,�t209 Contractor's 2F717 Application Accepted by Plred taf 466-6781 Additional Comments: [] Lodi - Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date _ �� 3 0 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 PERMIT NO. INFO EH 13-24 REV. 10/82 �� 10/82 500 14-26