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APPLICATION FOR PERMIT ` SAN JOAQUiN LOCAL HEALTH DISTRICT � {}4 1601 E. HAZELTON AVE., STOCKTON, CA 3Q PERMIT NO. Y J Telephone (209) 466-6781 R '�� DATE ISSUED113 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEREALTD DISTRICT (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 Subdivision Name Owner's NameAddresstLq�i Phone Contractor's Name j t License Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION*,, A l, [X AGRICULTURE WELL,. .r. t OTHER WELL • PITS/SUMPS INTENDED USE TYPE OF WtLI ROBLEM AREA CONSTRUCTION SPECIFICATIONS 1] Industrial U Open Bottom o Manteca Dia. of Well Excavation UDomestic/Private � Gra'v el Pack F-1 Tracy Dia. of Well Casing Public $ E] Other Delta Type of Casing L, Irrigation Appi x. El Eastern Specifications �] Cathodic Protection Depth - Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ WelI,Diameter, .,,,_ Sealing Material (top 501) _ Depth Filler Material (Below 50') f 1 TYPE OF SEPTIC WORK: NEW INSTALLATION' L REPAIR/ADDITION [] '�(No septic tank or seepage pit permitted if public sewer is T,. �Aavailable within 200 feet:) Installation will serve:y Resid_,�ence�r Commercial _ Other k Number of living units: Number of bedrooms 23_!Lot size _ f Character of soil to a d pth of 3 feet: �'� Ali. k Water table depth 1 SEPTIC TANK [ Type/Mfg -`— N— Capacity �,�f3 0 G�9�INo. Compartments _ PKG. TREATMENT PLT. Type/Mfg iCapacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well AD ^ Foundation Property Line 7 r DESTRUCTION d f 1 LEACHING LINE L_k-�"No. & Length of linesTotal length/sizer�JO FILTER BED Y-1 E] Distance toinearest� Well 1Foundation Property Line t/ SEEPAGE PITS ❑ . Depth '2„ok, {_ Size._: -3 Number! ' SUMPS lJ Distance to'lnearest: Well i Foundation Property.Line , DISPOSAL PONDS 1 I 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, 1 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 applican ust call fo 11 required inspections. -Complete drawing on reverse side_ •- ''" Signed Xr 6 ',Title: Dater 4TMEN SE ONLY _ Application Accepte yArea {� Stk 466-6781 Additional Comments -F<Lod 369-3621 Pit or Grout Inspection b Date 1:1 Manteca 823-7104 Final Inspection by Date 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 EH 13-24 REV. 10/82 14-26 E . mss?-•,` CX_ t#- { 10/82 500 FEE INFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, � L� /►vim', l0�-� (�.3 �-�V EH 13-24 REV. 10/82 14-26 E . mss?-•,` CX_ t#- { 10/82 500