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APPLICATION FOR PERMIT SP.N JOAQLiN LOCAL HEALTH DISTRICT 1601 E. ,IAZELTCN AVE., STOCKTON, CA Telephone .(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. � —W 7 t4 DATE ISSUED 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 o the San Joaquin Local Health District. Job Address[/ ��, q .....Subdivision Nam Owner's Nam ddress - , 33�: 1� . e . Phone . _ ;_�4 51f Contractor's Name. ,,,�■�!��,,—r` - License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT PUMP INSTALLATION SYSTEM REPAIR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA I❑ Industrial U Open Bottom ❑ Manteca F 1 Domestic/Private F-1 Gravel Pack E] Tracy 1] Public F—i other 1-1 Delta DESTRUCTION U LJ OTHER Lj DISPOSAL FED. PROP. LINE OTHER 14ELL PITS/SUMPS CONSTRUCTION SPECIFICATIONS Dia, of Well Excavation Dia. of Well casing:., LEACHING LINE No. & Length of lines Type of Casing ".Z — ye /�t- Total length/size ,Z X 2 - irrigation Lri 9 Approx. � Eastern Specifications ^' _ i G (?r Foundation C b ! Property Line 0. r ❑ Cathodic Protection Depth -Depth Depth -of Grout Seal' x' Geophysical Distance to nearest: }' Foundation Property'L-.ine ,. DISPOSAL PONDS Type of Grout U Other Surface Seal Installed by Repair Work Done FJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve:, Residence � Commercial..-� Other available within 200 feet.) Number of living units_. :3 Number ofr-bedrooms_rs Lot size Character_of�soil to a depth of 3 feet: L .w Water table depth SEPTIC TANK' n Type/Mfg ��%� Capacity No. Compartments 2 PKG. TREATMENT,PLTf r. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Lr Foundation ila J Property Line DESTRUCTION LEACHING LINE No. & Length of lines _ _ — ye /�t- Total length/size ,Z X 2 - FILTER BED Distance to nearest: _ Well _ i G (?r Foundation C b ! Property Line 0. r SEEPAGE PITS - -Depth -Size', Number r SUMPS Distance to nearest: Well Foundation Property'L-.ine ,. DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance,wi6,,San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a' 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 appli;61,"1411 ant ust call for al r quired inspections, Complete dra/y/�ng on reverse side. Signed X v Title: �,_. Date: —/�-cam FOR DEPARTMENT USE ONLY Application Accepted by7& Area Stk 466-6781�u Additional Comments: k Lodi 369-3621 Pit or Grout Inspection dv A A Date LJ Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return all copies o: Envir menta Health Permit/Services 16 1 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 5, coo 5' 1 EH 13-24 REV. 10/82 10/82 500 14-26