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v APPLICATIM FOR PERMiT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. WELTON AVE,, STCCKTON, CA PERMIT NO, — Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 it 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 Address R(wil JV. � subdivision Name Owner's Name __jEJfA 4,1,k '1/7A' Address Phone Contractor's Name , 4e Fu��( � License No, _,2 ,:Z- Phone a. TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT L] DESTRUCTION rn PUMP- INSTALLATION SYSTEM REPAIR U OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER 1_1NES-N DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'INTENDED USE T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Lj Industrial U Open Bottom' D Manteca Dia. of Well Excavation Domestic/Private L� _ Gravel `Clack Ej- Tracy Dia, of Well Casing 17 Publ is , �j Other . E]feel to V u' Irrigation Approx..' Eastern Type of Casing De th. Cathodic Protection p �� Specifications, } .�+ Depth of Grout Seal Geophysical.. ,,. ,,, 4 = "_ Type of Grout LJ Other Surface Seal Installed by _- Repair Work Done Type of Pump ` H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth , Filler Material (Below 50') 41 TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION . (No septic tank or seepage pit permitted if public sewer is O _ • available within 200 feet.) Installation will serve: Residence Commercial Other i Number.of living units: Number of bedrooms Lot size ► Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK FA Type/Mfg-_ Capacity No. compartments iPKG! TREATMENT PLT. Type/Mfg ' Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: WellFoundation F Property Line DESTRUCTION ❑ LEACHING LINE L No. & Length of lines Total length/size FILTER BED Distance to nearest: Well /�/j Foundation Property Line SEEPAGE PITS F—j Depth Size Number SUMPS Ej Distance-to nearest: Well Foundation Property Line 9 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 iicersed 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 California." The-applicant_mustcalyfor 1 requ ed inspections. Complete drawing on reverse side. Signed XTitle: _��e.s.�K .� . Date: Aw'� •^ '��"`��ta'►►��`--- DEPARTMENT USE ONLY Application Accepted by Area13 ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspectionfk Date Manteca 823-7104 o Final Inspection by Date — 1 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmertal Health Permit/Services 1601 E. Hazelton A P.O. 30x,20o9, Stk., CA 95201- . � FEE`' x BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT5_, PERMIT NO. INFO EH 13-24 REV. 10/82 _ 10/82,500 14-26