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_ P APPLICATION•F04 PERMIT SA.N JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District, Job AddressSubdivision Name Owner's Name 0 E5 Address 2 6" r( Phone Contractor's Name License No. Phone 1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑Gravel Pack [} Tracy Dia. of WeT1;;CAsing ❑ ; P.ubt is Other Del to ❑-, ❑ ❑ Type of Casing Irfigation Approx. ❑ Eastern Specifications Cathodic Protection o 71 Cathodic Depth of Grout Seal ❑Geophysical Type of-Grout ❑Other Surface Seal Installed by V. Repair Work Done ❑ Type of Pump H.P. State Work Done ! Well Destruction ❑ Well Diameter Sealing Material (top 50') - ;? Ir Depth Filler Material (Below 50') "1 C TYPE OF SEPTIC WORK- NEW INSTALLATION 71REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: µ ,Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: y . Capacity NoCompartments SEPTIC TANK �j Type/Mfg p PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line Ik DESTRUCTION / O LEACHING LINE [ No. & Length of lines /U X;9 A 7 x 10 Total length/size _ € I�"r_Foundation Property Line C - FILTER BED Distance to nearest: Well t _ _ sl/ SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line � x DISPOSAL PONDS ❑ �` '� -�� -- ' I hereby certify that 1 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. V f_- J 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 slcompensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that li'th'eap '.formanc'e of.the'wo'rk far which this permit is issued, I shall employ persons subject to workman's compensation laws of'Californi !�`, The applicant must ca fo 11 r//��eq fired inspections. 4Complete drawing on'reverse side: t. c.0 Date.3 ' Signed X! <� '�,r - ".. �. Title_ FOR DEPARTMENT USE ONLY Stk ...466-6781 f Application Accepted by .'. Area "' � _ �. k �" Lodi 369-3621 Additional Comments: t or Grout Inspectio by Date anteca 823-7104 Pi t Date Tracy 835-6385 Eiral_Inspection by. rp key. r Applicant - Return all Co P1 En vi onmental Health Permit/Services 6 F. Ha els n Ave., P.O. Box 2009, Stk., CA 95201 -<. _ - 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 14 I . _ �., • 10/82 500 EH 13-24 REV. 10/82 - 14-26