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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL`,HEALTH DISTRICT " x1601 t, HAZELTON"AYE., STbCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , (Complete in Triplicate) R 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 � Rules and Regul tions- of the Sa Joaquin`Local Health District. d res Nd r1/ Subdivision Name Owner's Name Address A Phone 3 ��!G Contractor's Name W r License No. .117.47 46,7116 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP-INSTALLATION SYSTEM-REPAIR —❑n�--�-•-^�^`��OTHER -•Q """ '"" DISTANCE TO NEAREST: SEPTIC TANK �� Q SEWER LINES 1,Q!J _ DISPOSAL,FL D. �^� PROP: LINE Q1� FOUNDATION AGRICULTURE WELL `t OTHER WELL ^' PITS/SUMPS Z6—,49 F, INTENDED USE "" TIPE OF 4lELL' PROBLEM AREA CONSTRUCTION SPECIFICATIDNS' Industrial ❑Open Bottom E]Manteca Dia. of Well Excavation -a Domestic/Private Gravel Pack []Tracy Dia. of Well Casing _ Public ]Other Delta ;❑ Type of Casing -� ❑ Irrigation App x. ❑Eastern Specifications _• � ,,} d❑Cathodic ProtectionDepthDepth of Grout Seal ,y sO W ❑GeophysicaI Type of Grout bV C . ❑Other Surface seal Installed b �r r / `. Repair Wark Done [] Type of Pump \! H.P. State Work Done Well Destruction ❑ 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 Commercial Other /o( Number of living units: Number of bedrooms Lot size /S Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method.of Disposal SEWAGE SYSTEM Distance.to nearest: Well Foundation Property Line ; DESTRUCTION— LEACHING ESTRUCTION—LEACHING LINE ❑ No. S. Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LJ Distance�to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �� ,� 1 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. t Home owner or licensed agent's signature certifies tYi'e 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 workmant.compensation laws of California." Contractor's hiring or sub-contracting signature certifies-the-f.olTowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject-to workman':scompensation'laws of California." 1 The applic u c 11 required inspections. Completed ag o/ry reverse side,. Signed �G�-�^� Title: 1 0 At 0, 09 ATO Date: ApTMEU USE ONLY FOR DEP Application Ace ed by Area f SStk 466-081 Additional Comments: r- --- _ `' ❑ Lodi 369-3621 Pit or Grout Inspection by Date- -w,3'�__ ❑ Manteca 823-7104 Final Inspection by Date -�" ^ * ❑ Tracy 835-6385 Applicant - Return all copies to:i Environmental 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 W wx EH 13-24 REV. 10/82 10/82 500 14-26