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} 3 l # APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 7-- 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 8 3 �f Telephone (209) 466-6781 �7 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 Joaquin Local Health District. Job Address i Subdivision Name Owner's Name p 3 Address Phone Contractor's Name License No.. 2-62463 Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DES.TRUCTION U p � PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ _ _ i ..x INTENDED USE „ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -C I J Industrial A��f Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing Public [-i Other Delta Type of Casing Irrigation Approx. [] Eastern Specifications Cathodic Protection Depth > ❑ tiDepth of Grout Seal ❑ Geophysical Type of Grout Other Surface Seal Installed by 111 . r Repair Work Done E] Type of Pump H.P. State Work Done - 7 Well Destruction ❑ Well Diameter Sealing Material (top�50`)�-� ^° k r � f Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U .,(No septic tank or seepage pit permitted if public sewer is (x/} available within 200 feet:) (� Installation will serve: Residence X_ Commercial Other p Number of living units: .Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water,table depth, SEPTIC TANK Type/Mfgq fZIS o C Capacity DO- No. Compartments- PKG. TREATMENT PLT. El Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to'nearest: , Well / Foundation Property Line DESTRUCTION - — LEACHING LINE No. & Length of lines ?j �'� J �� Total lengA/size FILTER BED ❑ Distance to nearest:- Well p'Q Foundation -- c Property-Lines - Y SEEPAGE PITS ❑ Depth Size Number +, SUMPS �K Distance tc,nearest: Well : 1c, 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 J 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 workman5 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 ust c I for requir ctions. Complete drawing op reverse ide. Signed X Title: r- )4, Date: 7 Z/"_a_ - - F DE RTMFNT_U ONLY \ ❑ Application Accepted by A -fi781 Area _ Stk 466 Additional Comments: ,Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 F ^ �.- Ffinal`Insp'ec"tiah-by n .._W T - - - - DateTracy 835-6385 Applicant - Return all copies to: nvironmental Healo Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 =BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 1-7 af 10/82 500 I EH 13-24 REV. 10/82 14-26