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APPLICATION'FOR PERI'IT 7 r° SAN JOP.QUi" LOCA! HEALTH DISTRICT * 1601 E. HAZELTON AVE., STOC"KTON, CA [/ ,. PERMIT NO. X3— 66 Telephone (209) 466-6781" 4 PERMIT EXPIRES I1YEAR FROM DATE ISSUED DATE ISSUED 17 �� /� (C pp., nT Triplicate} � Application is herebymade to the San aquir Local He?a strict fora ermit t p o cons ct and/or install the work herein described. This application is made in compliance with San Joaquin County Ord- nce No. 549 for sewage or No. 1862 for well/pump and the Rules (dI Regulations of the San Joaquin Local Health District, Job Address O �� Subdivision Name � 573-�6er� Owner's Name e s s Phone Contractor's Name License No, (,2— Phone f TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS41 f. INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS I Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel PackTrac ❑ Public Other ❑ y Dia. of Well Casing i . , C—J ❑ Delta 'Irrigation; Type of Casing ._ Approx. ❑ Eastern ❑Cathodic Protection _ Depth , Specificationsk ❑Geophysical Depth of Grout Seal Com, Other CLAtG} Type of Grout (� i f Surface Seal Installed by Repair Work Done ❑ Type of Pump r^, H.P. d State Work Done)&Z_.( Qp { 4f Well Destruction ❑ 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 is1� ! Installation will serve: Residence _ Commercial Other available within 2OO feet.) ' Number of}living-units: Number of bedrooms Lot size ~ !'I character of soil to a depth of 3 feet: Water table depth SEPTIC T t ANK 3 T e f �• ❑ YP /M 9� Capacity No. Compartments ! � PKG. TREATMENT PLT. T e Mf f ❑ yP / 9 Capacity Method of Disposal SEWAGE SYSTEM - , Distance to nearest: Well Foundation Property Line< DESTRUCTION. ❑ ��. -�„ - .� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance{to nearest: Well Foundation Property Line R , SEEPAGE PITS ❑ De th p I" Size /'�� Number SUMPS i � ❑ Distance to nearest: Weil Foundation Property Line Awl DISPOSAL PONDS ❑I w. :f- l x 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 owneror licensed agent's signature certifies the following: "I certify that in the performance of the work for which this 1k permit is issued, I shall not employ any person in such manner,as to become subject to workmant 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' ust pall far all quired i"n spec � ns. Complet drawing on reverse side. " Signed ( A-44.tIe:- Date: F DEPARTMENT US ONLY df Application Accepted by Area �_ E] Stk 466-5781 Additional Comments: Lodi 369-3521 Pit or Grout Inspection by Date ❑ Manteca $23-7104 Final Inspection by Date �.2 ❑ Tracy 835-6385 :,;,,;,Applicant -lReturn all copies'to:- En vi ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " J FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. 33 INFO Q +`�E3 � 'EH 13-24 REV. 10/82 " 1426 10182 500