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APPLICATION,FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON„CA., PERMIT NO. Telephone (209) 466-6781 '' DATE ISSUED PERMIT EXPIRES I. YEAR FROM DATE ISSUED` _ (Complete in Triplicate) Application is hereby made to the Sa 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. ��- l�pump ,'and the Rules and Regulations of the{San Joaq in Loc 1 Health District. -- Job Address ,/!� "'�©s �� Subdivision Name C3 -� Address Phone Owner's Name 12— Phone Contractor's Name License No. TYPE OF WELL/PUMP WORK: _ NEW WELL QWELL REPLACEMENT _0 DESTRUCTION PUMP INSTALCATION SYSTEM REPAIR OTHER�O fDISPOSAL�FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES 4 FOUNDATION I AGRICULTURE WELL 1 OTHER WELL # PITS%Sl1MPS j INTENDED USEI TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . Excavation ? - Industrial ;; { �Open Bottom �Manteca Dia. of Well _ � ( �•r� 1J Domestic/Priiaja Gravel Pack []Tracy ;Dia, of Well Casing '. Public F-1 Other Delta Type of Casing Irrigation Approx. Eastern Specifications " eDepth ❑Cathodic Protection .DeotBal h� fr.rou t Geophysical Ty pe of Grout sl 1,�l 1I Other Surface Seal Installed by / State Work Done E Repair Work Done Type. of Pump d /r 1 , i ) Well Destruction Q Well Diameter t�_ sealing Material (top 50') # ` Depth 1A Filler Material (Below 50') ) -- _..-._ -- -• 1t ermittedzi -pub+icaseweris..-- Y TYPE OF SEPTIC WORK: NEW INSTALLATION yREPAIR/ADDITION �U (No sep is lank or sed 9e P available within 200 feet.} Commercial _ Other Installation will serve. Residence . L 1 � _ �`�' o Lot size l Number of living units: Number of bedrooms S �- Water table depth' Character of sopl to a depth of 3 feet: p,. Capacity N,o Compartments- _2 Type/Mfg _ SEPTIC TANK ] PKG. TREATMENT PLT. �+u-� Type/Mfg Capacity Me*hod of Disposal `--— oper`t Line �P� SEWAGE SYSTEM Distance to-nearest: Well Faundatioh"3S �y DESTRUCTION i LEACHING LINE 3 No. & Length of lines J Total,-length/size ' Foundation _3 i Property�Line FILTER BED Distance to nearest: Well SEEPAGE PITS [] Size. Numbery. a F •�-w i > Depth,, , Foundation DISPOSAL Property Line ?>> E SUMPS U -'Distance to nearest: Well ; DISPOSAL PONDS t } I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed a'gent's signature certifies the following: "I certify that in the performance of the, work for which this permit is issued,iI shall not employ any-person in such manner-as.-to.,become-subject to-workman-�-compensation laws of California." k 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 applicant must cal reqinspections. Complete drawing on reverse side. 1,te- Date: Title: Signed X c __, FOR DEPARTMENT USE ONLY Area Stk 466-6781 Application Accepted by Lodi 369-3621 Additional±Comments: Date Manteca 823-7104 Pit or Grout Inspection byTracy 835-6385 Final Inspection by Date Applicant - Return all copies to:��_�H,,lthPermit/Services 1601 E. Hazelton .Ave., P.O. Box 2009, Stk„ CA 95201 FEE BASE ;AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ' L 10/82 500 EHw13-24 R6V.µ10/82 14-26