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F � APPLICATION FOR PERMIT I. MUM—S SEP�IC & SEWER SERVICE SAN JOAQUIN LOCAL HEALTH DISTRICT 2B So. 0,,6 � Ca'if. 95205 (1601 E. HAXELTON AVE., STOCKTON, CA PERMIT NO: ' Telephone (209) 466-6781 r" (:rrfr# 1:^,r s Lic. #267:]7._ �r 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 Jo uin Local alth District. Job Address ��. 5ubdi 'ion Name ' Owner's Name Address Phone y Contractor's Name License No.-.2 Phone . (� TYPE OF WELL/PUMP WORK: NEW WELL Q iWELL REPLACEMENT [] DESTRUCTION _ PUMP INSTALLATION E] SYSTEM REPAIR OTHER �Xl DISTANC€ TO NEAREST: SEPTIC TANK 4SEWER LINES + DISPOSAL FLD. y PROP. LINE W FOUNDATION I AGRICULTUR€ WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF; WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U 1 Industrial ; q Open Bottom Manteca Dia. of Well Excavation 17 Domestic/Private: ❑Gravel) Pack Tracy Dia, of Well Casing �I 0 PublicOther Delta I ff �j I , Type of Casing irrigation i Approx. EJ Eastern Specifications ? E] Cathodic Protection Depth }t- Depth of Grout Seal ` Geophysical 4 u Type of Grout U Other Surface Seal Installed by � Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth ( Filler Material (Below 50') t TYPE.OF SEPTIC WORK: NEW INSTALLAThON JV REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residenavailable within 200 feet.) Number � Commercial _ Other Number of living units: � 'Number of bedrooms Lot size Character of soil to a depth of 3tfeet: Water table depth SEPTIC TANK ] Type/Mfg Capacity 6 No. Compartments PKG. TREATMENT PLT. Type/Mfg 'I Capacity Method of Disposal Distance to nearest: Well &6r< Foundation Property Line - — _ 1 1 LEACHING LINE No. & Length of lines _ Total length/size FILTER BED Distance to nearest; Well Foundation Property Line SEEPAGE PITS Depth _ Size Number _ ��O r H SUMPS s lJ Distance to nearest: Weil ! Foundation —rte— Property Line ► DISPOSAL PONDS i 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 workmant 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 i this permit is issued, I shall employ persons subject to workman's compensation laws of California." } The applicantt!e11 for all reuir inspe ions. Complete drawl esTe cse: id , Signed X � Title: Date: •- OR DEPARTMENT USE 9NLY Application Accepted by Q� - -!,r3 Area 0� Eq- Stk 466-6781 ) ". Additional Comments: 0/,/Q4/ ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 r Final Inspection by al Date f-F� 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton A P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED . RECEIVED BY DATE PERMIT NO. INFO " 1 w T CP113 3 �3-S�3 . EH 13-24 REV. 10/82 - a - n 10/82 500 4 14-26 _ `