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L1 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL'"HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Qty q q ` 1` Telephone (209) 465-6781 g 4f PERMIT EXPIRES I YEAR FROM DATE ISSUEp DATE ISSUED ~"3 (Complete in Triplicate) x Application is hereby made to-the San Joaquin Local Health District for a permit to const", ct 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 andg Q A C'CC Regulations of the n Joa uin.ttpc Health District. Job Address_ �J 1% !(cl 5•ub�divisi n Name G� Owner's Name CRAI& 01gJT _ Address j~Q• �C�►Y 1�0 Umbf- � . Phone ��•�� Qp N Contractor's Name License No, Phone 0 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ 0pen Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private U may,❑ Gravel -Pack ❑ T�a�y —.pia..of,Well.Casing"; ❑ Public s ❑ Other ❑ Delta Type of Casing j [`1 irrigation ; Approx. ❑Eastern Depth Specifications " F-1Cathodic Protection ,.� i Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ IType of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') 0 'Depth Filler Material (Below 50') - Q TYPE OF SEPTIC WORK:1 NEW INSTALLATION, REPAIR/ADDITION ❑ (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: �_ Number of bedrooms — Lot size �•� IJ2 �� Character of soil to a depth of 3 feet: r Water table depth m SEPTIC TANK `AL Type/Mfg C6JVCkZrC +L 'P1206Crapacity 11400 C J4L No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance-to nearest: Well . Foundation Property Line m DESTRUCTION ❑ LEACHING LINE No. & Length of lines 3 LIN CS O F Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ] Depth Size 33" Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 4 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'l.aws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's si ature certifies the following: "I certify that in the performance of the work"for which this i permit is issued, I shall not emp by any person in such manner as to become subject to workman compensation laws 6E; alifornia." Contractor's hir g o ub-c tr ting signature certifies the following: "I certify that in the performance of the work for which permit is this pehi 1 ploy persons subject to workman's compensation laws of California." ti The applicant ,l f 11 require inspections. Complete drawing �n reverse side. II Signed X Title: Date4 Oel �16IF-f F DEPIRTMENT USE ONLY Appl is ti Accepted by - - - Area SJ 66-6781 ? Additional Comments: Lodi 369-3621 ❑ I Pit or Grout Inspection by _ Date r-2Z-* ❑ Manteca 82327104 Final Inspection by Date �J ZZ "Tracy 835~6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO {{i EH 13-24 REV. 10/82 /� f { /� I �C-4zy- p 10/82 500 a 14-26 I