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APPLICATION FOR PERMIT SAN JOAQLI,,- LOCAL iiEALTH DISTRICT 1601 F. HA7ELTON AVE., STOCKTON, CA PERMIT N0. 'Eli —SC; 6 Telephone (209) 466-6781 A 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 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 Regul tions of the San Joaquin Local Health District. Job Address` �p 4, _ Subdivision me Owner's Name 1Jy Address �`fvdp uc Phone Contractor's Name v t' ._,A.k License No. 3 Z 4 7� Phone r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom E] Manteca Dia. bf Well Excavation -— - U Domestic/Private 7 Gravel Pack ❑ Tracy Dia, of Well Casing �] Public r-1Other E] Delta Type of Casing Li irrigation Approx. Eastern Specifications- Cathodic Protection Depth Depth of Grout seal Geophysical LJ Other Type of Grout Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done 0 Well Destruction LJ Well Diameter Sealing Material (top 50') _ 0 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ iTION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence r Commercial _ Other Number of living units. f Number of bedrooms —3 Lot size Character of soil to a depth of 3 feet: / t�Q / ,,_ Water table depth �`] (2 I SEPTIC TANK Ej Type/Mfg 01 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method df Disposal SEWAGE SYSTEM IIo� Distance to nearest: Well Foundation Property Line DESTRUCTION L-1 LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth —?_=—lam— size �v * Number SUMPS Distance to nearest: Well !1[3o Ll"'Foundation ) Lf-- Property Line DISPOSAL PONDS ❑ �� fT 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, I 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% st "caller for(}all wired inspections. Complete drawing on reverse side. Signed X jy►tL�J� Ate, } Title: /�� _ __ Date: F R EPARTMENT USF ONL Application Accepted by Area Stk 466-6781 A itional Comments: Lodi 369-3621 Pi or Grout Inspection by Date Manteca 823-7104 PP Final Inspection by Date r Tracy 835-6385 Applicant - Return all copie to: Environmental Hea h Permit/Services 1601 E. Hazelton Av P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26