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APPLICATION FOR PERMIT SAN.JOAQL'iN LOCAL HEALTH DISTRICT 1601' E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J3' 130;5 Telephone (209) 466-6781 nn �V 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 �,/ % Subdivision Name a- - J., Cd Owner's Name AV__ Address 115,4011,� ' Phone ? Con-ypactor's Name License No. jro.0 %1 / 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 FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ 0pen Bottom [] Manteca Dia. of Well Excavation ❑ Domestic/Private [] Gravel Pack [� Tracy Dia, of Well Casing ❑ Public ❑ Other ❑'Delta Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ Geophysjeal Depth of Grout Seal Type of Grout U Other • Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction [j Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence L-- Commercial _ Other Number of living units: _-I— Number of bedrooms -- Lot size Character of soil to a depth of 3 feet- ,a- M Water table depth �4tj SEPTIC TANK '[f'-Type/Mfg c fe�i� - Capacity Z7 No. Compartments 71 pU V --I:: _J U41— PKG. V PKG. TREATMENT SEWAGE SYSTEM PLT. F-1 Type/Mfg Capacity Method of & 5 4 Q i Property Line Disposal RECEIVED BY ❑ Distance to nearest: Well Foundation .11-01 DESTRUCTION LEACHING LINE No. & Length of lin(S-.22 11 Total length/size FILTER BED Distance to nearest: Well`0' Foundation 80 1 Property Line SEEPAGE PITS L, Depth �S Size of Number, -2— SUMPS LJ Distance to nearest: Well �^ Foundation (0 Property Line 30' DISPOSAL PONDS ❑ 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 applicantR7st 1 fo all required inspections. Complete drawing on reverse side. Signed X Title: 19ctnti Date: 1113 OR DEPARTMENT USE ONLY j Application Accepted by "tj Area ❑ Stk 466-6781 Additional Comments: T `odi 369-3621 Pit or Grout Inspection JDate LEI—Manteca 823-7104 Final Inspection by Date t ❑ Tracy -835-6385 Applicant - Return all copie/tdV Envircdnmental 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 EH 13-24 REV. 10/82 1/ 1/ ij 10/82 500 14-26