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i� APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 t 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 thelSan Joaquin Local Health District. Job Address_ 4" Subdivision Subdivision Name Owner's Name Address Phone Contractor's Name S P`S[r,�3License No. Phone Q r TYPE OF WELL/PUMP WORK: NEW WELL J WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR,. �- OTHER DISTANCE.TO-NEAREST: SEPTIC-TANK .- ... SEWER-LINES , j14DI$POSAL�FL-D. -�—PROP:—LINE'-- - -�— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial, - ,.� Open"Bottom Manteca Dia. of Well Excavation U Domestic/Pri}vate. E]Gravel Pack �` Q_Tracy Dia. of Well Casing .� Publ isi` CJ Other �J Delta J Irrigations A Type of Casing o Approx. Eastern Specifications Cathodic Protection P ❑Geophysical T Depth of Grout Seal = Other ij Type of Grout 6 Surface Seal Installed by Repair Work Done 0 Type of Pump 1 H.P. State Work Done Well Destruction ❑ Well'Diameter Sealing Material (top 50') w° !? Depth ` !� Filler Material (Below 50') A V TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIT_ION jJ '(No,septic tank or seepage pit permitted if pub].ictsewer is available within 260 feet.) Installation will serve: Residence Commercial _ Other Ave-L tys� Number of living units: Number of bedrooms Z — Lot size Character of soil to a depth of 3 feet: .4,W Water table depth 1IF-0 fi SEPTIC TAMC Type/Mfg " Capacity ,/,g!_49e, No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM;" Distance to nearest: Well F Foundation --Pro ert Line DESTRUCTION Q p y '' LEACHING LINE,, �' No. & Length of lines — zjj*i r Total length/size" �� r-w `'� FILTER BED Distance to nearest: Wellf�/�! Foundation — Property Line i ° SEEPAGE PITS ;9 Depthr1w _z j Size ZYS I Number "'- SUMPS c U Distance to'nearest: Well /,�PlJ s Foundation Property Line Y U DISPOSAL PONDS ❑ I hereby certify that I have preparedithis application and that the work will be done iri 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 workmans 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 com.pensatian laws of California." The applicant m t call f all a uire pections. Complete drawing on reverse side. Signed X Title: Date: f FOR DEPARTMENT USE ONLY Application Ace ed by Area �P Stk 466-5781 - - ,` Additional Comments: Lodi 369-3621 Pit 'or Grout Inspection bygg�w�) Date _ �j L4-S 1 Manteca 823-7104 Final Inspection by rDriDate _6—i r-E)LLt L Tracy 835-6385 k 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. ;sv `.INFO y q- H -6-gid REV. 10/82 14-26 10/82 50D ;