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APPLICATION FOR.PERMIT SAN JOAQUirl LOCAL HEALTH D1� TRICT (c 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ,T� 4c=m) cot. 95205 Telephone {209} 466-6731 zY:�s0. SIO ��;�7 DATE ISSUED c';1 G1G3 3%J9 �.OSii'v?,Ao. E 1-�� 1, PERMIT EXPIRES 1 YEAR FROM DRTE ISSUED {Complete in Triplicatej}j 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-Joa in Local He lth District!' Job Address r Subdivision, Name Owner's NameIF . - Address Phone Contractor's Name License No. } Phone } TYPE OF WELL/PUMP WDRK: NEW WELL Q WELL REPLACEMENT +!J DESTRUCTION -PUMP 'INSTALtATION SYSTEM REPAIR 'a OTHER t DISTANCE TO .NEAREST:.SEPTIC TANK_ SEWER LINES _DI_SPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL N OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial U Open Bottom Manteca FOia, of Well Excavation LJ Domestic/Private Gravel Pack Tracy iDia, of Well Casing l7 Public LJ Other s Delta , ' -... .. -1- 1—. Irrigation l! �jype of Casing �j 9 Approx. Eastern; Depth Specifications ❑Cathodic 'Protection hf s - = Depth of.Groutl Seal Geophysical Type of Grout 4. U Other i 'Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. �. _ :.KState Work--Done; Well Destruction U Well Diameter. Sealing Material (top 50') �• Depth Filler Material- (Below 50'; x d TYPE OF SEPTIC WORK: NEW INSTALLATION U .REPAIR/ pN U {No Septic tank or seepage pit permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence _ .Commercial 's.. tOther Number of living units: Number of bedrooms Loft size , !� Character of soil to a depth of 3 feet:.' w i Water table depth SEPTIC TANK �! Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, Type/Mfg f` Capacity Method of Disposal- s SEWAGE SYSTEM Distance to nearest Well Foundation Property Line DESTRUCTION i I LEACHING LINE No. & Length of lines �3 Total-length/size c7 FILTER BED Distance to nearest: Well � 27 r_ Foundaton __/ -f •;Property- Line o� SEEPAGE PITS � Depth Size � - ,.,Number SUMPS iJ Distance to nearest: Well �QO 1 Foundation /Q Property Line st`` DISPOSAL PONDS D ;. �! 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 cf 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'tsecome 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 applicant l for all requ e_ spec s. Complete draw Signed X Title: Date: /,0—�] z Application Accepted by Ai;ea _Z.... [ Stk 466-6761 Additional Comments: _ LJ Lodi 369-3621 CZ} PitSor Grout Inspection by., �/ -rD.�te/�=S: Manteca 823-7104 ! / Final Inspection by Date �lJ-b� j ` Y Tracy "835-6385 Applicant - Return all copi to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P,O, Box 2009, Stk., CA 95201 I y�. r1N BASE- AMOUNT [DUE AMOUNT REMITTED RECEIVED BY 0 TE'f�. PERMIT N0. O a. ' S I I EH 13-24 REV. 10/82 _ 10/82 500 14-26