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I APPLICATION FOR PERMIT i SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. '93--11`7ld Telephone (209) 466-6781 . RATE 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 w ' described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump l and the Rules and Regulations of th San Joaquin Local Health District,. Job Address Subdivision Name Owner's Name (—. Z 7!• Phone Contractor's Name AD icense No. 3 7 Phone ; { TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION { AGRICULTUREtiWELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,I FI Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation = f` r t� 2r.Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public Qther Delta w ❑ ❑. ❑ Type of Casing 1 -1'rri atiori.'"" `� Depth rox M� Eas`tern '— LJ 9 PP k. ❑ Specifications. Cathodic Protection ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑0ther i Surface Seal Installed by �p � .tib+ i✓ Repair Work Donee' Type of Pump H.P. State Work Done L'.0, Well Destruction ❑ Well Diameter Sealing Material (top 50') — � Depth Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ❑ (No septic tank or seepage,pit permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence Commercial. Other Number of livingof uno.a,de th of`j Number of bedrooms'ti y Lot,size ¢ 3 feet. _ f r Water table depth _ _'_. . __ __,_...a __Water } No. Compartments SEPTIC TANK U Type/Mfg. Capacity P 1 PKG. TREATMENT PLT.-{] Type/Mfgi'> - Capacity Method of Disposal SEWAGE SYSTEM '.Distance to nearest: Well Foundation Property Line':. DESTRUCTION r� LEACHING LINE ❑ No. & Len9th of lines Total length/size_ I s. FILTER BED ❑ Distance�:to nearest: Well Foundation Pro pertyFLine . SEEPAGE PITS Depth ` Size Number x SUMPS ❑ Distance to nearest- Well Foundation Property Line DISPOSAL PONDS ❑ �� I hereby certify that 1 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 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 Callifornia."I � 3 The applican ust all for equired ins. tions. a Ccrymplete drawing on reverse side. I Signed X tle: I7t t Date: a e OR DEPARTMENT USE ONLY y.n, ;= , 4 t 5tk 466-6761 Application Accepted`by-^'- , ,k f `1 "' - Area�}'S - ❑— Additional Comments: 1 Lodi 369-3621 Dat Pit or Grout Inspection e Manteca $23-7104 Final Inspection by Date L Tracy 635-6385 ti Applicant - Return all copie 'to: Envir,pnnt.:l Health Permit/Services 1601 E. azeltan Ave., P.O. IBox 2009, Stk., CA 95201 iiL,1 =BASE AMOUNT ,DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. O. �40e So IO/.82 500 EH 13-24 REV. 10/82 14-26