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,; APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. `(.a Telephone (209) 466-6781 DATE ISSUED 7 7 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. 1 (Complete in Triplicate) ' i 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.th6 San Joaquin Local Health District. Job Address 8010 E. Northland Rd. Subdivision Name Owner's Name X. A. Larson ;} Address 507 E. Center St., Manteca phone 823-2131 Contractor's Name none License. No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �❑ PUMP INSTAIIATION ❑ SYSTEM REPAIR Q OTHER I_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO, FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA ❑ Industrial ❑ Open Bottom ❑ Manteca FJ Domestic/Private ❑ Gravely Pack [] Tracy CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing PROP. LINE PITS/SUMPS ❑ Public ❑ Other.1 ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout OtherC � Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter'l Sealing Material (top 50') _ Depth Filler Material .(Below 50') _ r w TYPE OF SEPTIC WORK: NEW INSTALLATION j_1 REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is {{ available within 200 feet.) 2 'Installation will serve: Residence X Commercial _ Other Number of living units: Number of bedrooms 4 Lot size 1 21 x205 t Character of soil to a depth of 3 feet: sandy loam Water table depth @PPDX 121 SEPTIC TANK CJ Type/Mfgj Capacity No. Compartments 3 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE'SYSTEM Distance.to nearest:. Well Foundation Property Line DESTRUCTION 11 LEACHING LINE ❑ No. & Lehgth of linesl-'201 leach line Total length/size 1 Line tot 1 length 201 --- FILTER BED ❑ Distance. to nearest: Well 100f FoundationQT L� r Property Line 4� Jho SEEPAGE PITS ❑ Depth 1 Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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 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 became 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 appl' K_ - it must call for all re fired inspections. Complete drawing on reverse side. Signed X Title: owner Date: 7-1.83 F R DEPARTMENT USE ONLY ❑ Application Accepted by Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection byDate j❑ Manteca 823-7104 Final Inspection by i� Date Tracy 835-6385 Applicant - Return all copi o: .J' Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO b '� SJ— C &3 ti EH 13-24 REV. 10/82 �'10/82 500 14-26