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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. f Telephone (Z09) 466-6781 DATE ISSUED 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 of the San Joaquin Local Health District. Job Address �, (]/,� vr` 4 '�- Subdivision Name f Phone Owner's Name - Address f Contractor's Name fAL `se No, - Phone 3 - TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT' DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 1-1 OTHER ❑ 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 —L2- 11 �r Diell Casing 1 + OomesticlPrivate ravel Pack Tacy � �a _of.W.�� O ra i y �Publics �� Other, Delta Type of Casing V Irrigation Approx. Eastern Specifications S / Cathodic Protection p T - G Depth Depth-of"Grout Seal ----• "�` �`' ( J Geophysical 3`1 €rTy-pe.of Gro6t `. XPI ? {J Other _ Sur;face.Sea..,-.Installad.by State Work Done Repair Work Done E] Type of Pump H.P. + Well Destruction jJ Well Diameter Sealing Material (top 50') 4 1 I Depth Filler Material (Below 501) , TYPE OF SEPTIC WORK: NEW INSTALLATION (J REPAIR/ADDITION ❑ (No septic tank-or seepage,.pi.t-permitted tf�'$Ublic sewerais LA, i available within 200 feet.) Installation will serve: Residence _ Commercial Other ", z Number of living units: Number of bedrooms'`- Lot sie , Character of soil to a depth of 3 feet: Water table depth s SEPTIC TANK Type/Mfg �. Capacity No. Compartments 1. PKG. TREATMENT PLT. Type/Mfg Capacity Method of`Disposal SEWAGE SYSTEM Distance to 'nearest: Well Foundation.'---�'---•,-^^^—rPropertyeLine DESTRUCTION f No. & Length of lines Total- length/siz'e LEACHING LINE J 9 ' - .r. . t FILTER BED Distance to nearest: Well + ` Foundation ° Property Line ) h SEEPAGE PITS Depth Size - Number' i iert Pro Line SUMPS �� Distance to nearest: Well Foundation { Property ; - . :D I SPOSAL--PONDS I hereby certify that 1 have prepared this application and that the'work will be done in accordance with San Joaquin count , ordinances,,state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fol 3owing:.-I+certify,,.that,J n.the.performance of-the wor..k_for which this: permit is iII d, I shall not employ any person in such mariner as to become subject to workman•�.'compensation laws of California'." ' permit 1� shi.r_ing or sub-contracting signature certifies the following: "I certify that_in`the'.performance of the work for which Con this permitlis issued, Yshall employ persons subject to workman's compensation laws of California." i The applican ust al for a re wired inspections. Complete dra ' g on r verse side. Title: Date: Signed X i ; �i1lE A TMENT f ONLY tl Area �� Stk 466-6781 Application Accepted by 1 -- ❑ Lodi 369-3621 , Additional Comments: Pit or Grout Inspection by S, Manteca 823-7104 1 e �4 4 �' Date LJ Final Inspection by Date L 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 �7� �57-� 10/82 500 r•. EH 13-24 REV. 10/82 ' 14-26':