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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F 3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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. Thisapplicationis mad6 in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of toe San Joaquin Local Health District. Job Address Oil 2 tN4 Subdivision Name Owner's Name e R S Address Phone y6 Phone -2407- Contractor's Name 14 License No. I TYPE OF WELL/PUMP WORK: NEW' ❑ WELL REPLACEMENT � DESTRUCTIONEI '� ( it PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE `J FOUNDATION E1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE * WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial i �u Open Bottom .� F_�Manteca'K Dia. of Well Excavation Domestic/Private Grav�l..Pack. �Tracy Dia. of Well Casing Public [ Other C] Delta Type of Casing V Irrigation Approx.� 0 Eastern Specifications Cathodic Protection t)epth� Depth of Grout Seal 1-1 Geophysical t Type of Grout ! Other Surface Seal Installed by rD f HP"Repair Work Done Q Type of Pump ^" State Work Done + i Well Destruction U Well Diametersr Sealing Material (tap 50') — Depth 1 Filler Material (Below 50t) _J TYPE OF SEPTIC WORK: NEW INSTRLLRTION � REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence )Cx commercial-- Other Number of living units: _ _ Number of bedrooms. Lot size C• f I Water table depth 6� Character of soil t6 a-'depth'of.3 feet: — C . ComL Capacity No. SEPTIC TANK F * Type/Mfg t + t Method of 'Disposal 1 r PKC. TREATMENT PLT. ❑ Type/Mfg i Capacity. � . SEWAGE SYSTEM Distenc� to nearest:. Wel l `f4 Foundation troperty Line DESTRUCTION ❑ I I z i A— ' 111 LEACHING LINE No. & L2ngth of lines Total length/size i `l _i Foundation 'Property Line FILTER BED Distance to+nearest: Well f . III, Number /t SEEPAGE PITS [ - Depth �$� Size �3 SUMPS # �� Distance to nearest: Well /DC7 iFoundation 3 L� Property Line 3 D Y . DISPOSAL PONDS E I hereby certify that I have preparedSthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules.and,regulations ofRthe San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance ofithe work for which this permit is issued, I shall not emplay�aTy"rerson, n'sucti'manne-rlasito,become+subject to workmanIs compensation laws of California." Contractor's hiring or sub-contractingYsignatdlre cert-.fies'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." ! li The applicant must Cal for all . quire s t ns. .Completegdra/wi�ng�o rev/:w everse si L' Title: 1' S /:w9tJ - Date: Signed X ARTMENT USE ONLY Area Stk 466-67$1 Application Accepted by - ❑ odi 369-3621 Additional Comments: Pit 6r Grout Inspection by ` Date �� L] Manteca 823-7104 �)��/ ' Date �� ❑ Tracy 835-6385 Final Inspection by — !. y+�[ 1. �^^^` Applicant - Return all copies toi: Environmental`Health Permit/Services16 1 ,E. Hazelton Ave., P.O. Box 2009, 5t k., CA 95201 i FEE BASE AMOUNT-1 DUE" I AMOUNT REMITTED..,, RECEIVED BY DATE PERMIT NO. INFO + + 10/82 500 E EH 13-24 REV. 10/82 t:' 1446