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ti C wi APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES i 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 Joaquin Local Health District. Job Address 1 A Subdivision Name _ Owner's Name .S Address 1 q 3 1JOR 1'Y1A1�) ,�1)�_C Phone _44S! Contractor's Name License No. Phone _ n TYPE OF WELL/PUMP WORK: NEW WELL F_� WELL REPLACEMENT DESTRUCTION Uv PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack E] Tracy Dia. of Well Casing Public Fi0ther Delta Type of Casing Fjirrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done -� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: SALmber of bedrooms I_ _ Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg<09g Capacity 1 QQ No. Compartments �. PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well _ Foundation 424= J Property Line [©p/ DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well 1��'F Fourdation _TF Property Line (Q SEEPAGE PITS D Depth Size Number SUMPS Elt, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑4yO�� Will 1(l 6e— '7 1601 f yyk- jot-G 4-6-q 1 ec-4, Loi, ,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 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 California." The applicant u t call r all re fired inspections. Complete draw' g on reverse side. Signed X Title: Date: 0 ARTME.NT,4SE ONLY Application Accepted by Area --0-3-3 Stk 466-b781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection b, Date Manteca 823-7104 Final Inspection by Date Z✓r Tracy 835-6385 Applicant - Return all c to: Envir ent Health Permit/Services 1601 E. Hazelton Ave., P.D. Bax 2009, Stk., CA 95201 [FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. NFO EH 13-24 REV. 10/82 10/82 500 14-26