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f , APPLICATION FOR PERMIT SAN JOAQL'iN LOCAL HEALTH DISTRICT �q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (204) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressEj2 —15 Subdivision Name Owner's Name _�}'f, �, Lt� �C�7 �- Address Phone Contractor's Name s License No, Phone 444,& F — TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION L] SYSTEM REPAIR " OTHER U DISTANCE TO NEAREST: SEPTIO' TANK SEWER LINES DISPOSAL FLD. PROP. LINE (n] 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41 fJ Industrial 'I� U Open' Bottom Manteca Dia. of Well Excavation _ ❑ Domestic/Private Gravel Pack. Tracy Dia, of Well Casing Public t �j Other- ❑ Del to ' Type of Casing Irrigation IM Approx, Eastern Depth Specifications f-1CathodicProtection p Depth of Grout Seal � Geophysical Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well gDiameter Sealing Material (top 501) Depth'I� Filler Material (Below 50') 0 I TYPE OF SEPTIC WORK: NEW 6IJSTALLATION U REPAIR/ADDITIONUCI' (No septic tank or seepage pit permitted if public sewer is !n ! 'uC available within 200 feet.) Installation will serve: Residence X, Commercial _ Other Number of living units: Number of bedrooms Lot size 62? Character of soil to a depth of 3 feet: f _ Water table depth Zp f SEPTIC TANK ❑ Type/Mfg t Capacity F: - No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg "Capacity Method of Disposal . SEWAGE SYSTEM D€i stance to nearest: Well Foundation Property Line ' DESTRUCTION ❑ ��, LEACHING LINE No. & Length:of lines �9 f Total Iength/size C;Z'X ) ! FILTER BED f .,D1 stance to nearest: Well Foundation __ Property Line SEEPAGE PITS Dhpth f Size Number SUMPS "` L—� Distance to nearest: Well Foundation 3,, ' Property Line � y 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 a 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-contraji ' nature certifies the following: "I certify that in the performance of the work for which`'" this permit sued, I shal eons subject to workman's compensation laws of California." The appli 11 fo 11 nspections. Complete draw's reverse side. Signed Title: ' Date: �� D EPAR ENT D� Application Accepted€ y _ USE ONLY Area !�] St 466-5781 � Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by ` ar�.a, -0a�tre- U Manteca 823-7104 Final Inspection by-l� —� Date ❑ Tracy 835-6385 Applicant - Return all copillles to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 lM FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. k INFO 4 3 I EH 13-24 REV. 10/82 i� 10/82 Soo 14-26 f/ � ✓g {