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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTUN, CA PERMIT NO. �3g� Telephone (209) 466-6781 . �1y ' DATE ISSUED PERMIT EXPIRES 1 YEAR FROM OATE. ISSUED (Complete in.Triplicate) r r � Appl-ication 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: Job Address f Subdivision Name Owner's Name M Address Phone Contractor's N License No. Phone ! TY-PE OF WELL/PUMP WORK-., x NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ OfSTANCErTO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -FOUNDATION.-.— �--AGR1C-ULTURE-WEL=L r—OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL—:"PROBL-Y4REA- 5 CONSTRUCTION SPECIFICATIONS U) Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel `Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other. . ❑Delta Type of Casing I 6 Irrigation Approx. ❑ Eastern Specifications x Z Cathodic Protection Depth-❑ p_J Depth of Grout Seal + ❑Geophysical w Type of Grout U other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dore �. Well. Destruction ❑ Well Diameter Sealing Material. (top 509 4/ Depth j Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION. RERA ADDITION_❑ (No septic tank or seepage pit permitted if public sewer is .�/ available within 200 feet.) ' Installation will serve: Residence_Y Commercial Other Number of living units: - Number of bedrooms . ',Z— Lot size ... 7 Character of soil to a.depth of 3 fe�et:.�. Water table depth f � i SEPTIC TANK (� Type/Mfg gZe3j�r Capacity, Q C No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacnty Method of Disposal SEWAGE SYSTEM Distance to-nearest: Well Foundation Igg. Property Line DESTRUCTION �-�-- LEACHING LINE No. & Length of lines — Total length/size Q - FILTER BED ❑ Distance to-nearest: Well Foundation /Q Property Line f-f' SEEPAGE PITS Depth: o�.5 -. Size 33 ' _ Number SUMPS Distance to nearest: Well D b Foundation !D 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 oTthe San Joaquin Local Health District. k 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 becomesubject 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 appy t must call�fo 'll r gdired inspections. Complete drawing on reverse side. Signed X I f Ti t.1 Date: Ll —ILI ' '--•-- ----' FOR_ EP RTMENT_USF ONLY I Application Accepted b Area , ❑ Std 466-6781 ! [ Lodi 369-3621 i Additional Comments: Dat Por Grout Inspection by e r= ❑-Manteca 823=7704`" Final Inspection by Date �e/P�. � Tracy 835-6385 Applica - eturn all copies Environmental He th Permit/Services 16 1'E. "Hazel'ton•Ave., P.O. Box 2009, -Stk., -CA--95201 4 ,. .«----'.�n• ..��-�....ti,3:: v.�_ t vwr__."'spa.'...-.%...-._.Y., �._.��. __ _ -__ __- _ _. __ •f FEE ` BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO IO/82 500 EH 13-24 REV. 10/82 14-26