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APPLICATION FOR PERI SAN 30AQCiN LOCAL HEA-LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. $ � -719 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , Application is hereby made to'the'San Joagbin 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 and the Rules and Regulations of the San Joaquin Local Health District. Job Address_/021-7/. E .�lg,ST .RN R 0 • Subdivision Name Owner's Name / lPAly l>( J7 44, !S Address / ,e?" &10Phone Contractor's Name �License No. Phone II TYPE OF WELL/PUMP WORK: NEW WELL ❑ * WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK .� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U DQ J IndustrialdOpenBottom Manteca Dia. of Well Excavation U Domestic/Private"' � Gravveeel Pack Tracy Dia. of Well Casing Public 7-1 0 ht er " Delta Type of Casing 1' F�lIrrigation Approx. Eastern . Depth Specifications F-1Cathodic Protection Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done [j 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 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is v 'lable within p200 feet,) Installation will serve: Residence Commercial Other IV01.1k :r 3 Q Number of livingLt size units: / Number of bed ooms o e �q+ Character of soil to a depth of.Z feet: Water table depth ad SEPTIC TANK [] Type/Mfg. , . 8 C R t Capacity .?A0 D No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE a No. & Length of lines 3 4va 70 J'_ Total length/size Z49� FILTER BED Distance, to nearest: Well Foundation Property Line SEEPAGE PITS ❑ DepthSize Number SUMPS t_� Distance to nearest: Well Foundation Property Line 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 workmanis 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 personssubjectto workman's compensation laws of California." The app ant m` t call for al regu d inspections. Complete drawing on reverse side. 7v Signe�X ._t_ ar _ Title: Date: 83 DEPARTMENT USE ONLY' t Application Accepted by Area D b - [] Stk 466-6781 Additional Comments: f, - 'z Lodi 369-3621 Pit or Grout Inspection by % Date Manteca 823-7104 Final Inspection by Date 12��Z—Or3 V ❑ Tracy 835-6385 Applicant - Return all copie o:] Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEEBASE AMOUNT ©UF AMOUNT REMITTED RECEIVED BY DATE "PERMIT INFO a mss. � E EH 13-24 REV. 10/82 r 10/82 500 14-26 —S