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SEP i APPLICATION FOR PERMIT �I SAN JOAQL'iN LOCAL HEALTH DISTRICT UPI! sop 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _ aJ' i'�l�,}1,�I)� � Telephone (209) 466-6781 DATE ISSUED � �� F_Aa7`4 � � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate), Application is hereby made to the San Joa1.quin 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 -5-Ao Subdivision Name Owner's Name „—, (' n A 'Address 62Y4 4v_ Phone Contractor's Name ✓ _ �, License No. L nPhone TYPE OF WELL/PUMP WORK: NEW WELLV ELL REPLACEMENT DESTRUCTION _ PUMP INSTALLATION YSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER EINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d' I_Jin`dustria'l---b= - .u:Operi=Bo tam -," 3lanteca ._-.�; Dia,.o.f:.We17,Excavation. U Domestic/Private ❑ Gravely Pack [ Tracy Dia. of Well Casing Public 7Other + Delta Type of Casing Ljlrrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout .0 Other Surface Seal Installed by Repair Work Done E] Type of Pump M H.P. I State Work Done o> h, Well Destruction 0 Well Diameter i Sealing Material (top 50') _ ---.... Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLAThON U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is �[ available within 200 feet.) Installation will serve: Residence Commercial Other p Number of living units: Number ofbedrooms Lot size ~ 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments R PKG. TREATMENT PLT, [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance �to nearest: Well Foundation Property Line DESTRUCTION ❑ 11 LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth I size Number SUMPS "-L—i Dis'tanc'e°to nearest: Well - Foundation -Property Line. DISPOSAL PONDS ED -- l — 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, [ 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: 1lnti..a.y,., _ Date: !rj -U FA DEPARTMENT USE ONLY Application Accepted by I Areav T a Stk 466-6781 Additional Comments: D Lodi 369-3621 Pit or Grout Inspection by Date El Manteca 823-7104 Final Inspection by Date Q t� Lj Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pernt/Ar_Services 1601 E. Hazelton Ave., P.'0. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 5 � 3 X3- 105 EH 13-24 REV. 10/82 10/82 500 14-26