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APPLICATION, FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT # � 14— 1601 E. HAZELTCN AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) Application is hereby made'ta the Sari 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 d e la io /the iS,aln JJJo�aquin Local Health District. 4-7 F1 �^- Job Address _� !VIJVO Subdivision Name C ra r Owner's Name C,a F7-rF OCAress lil Z01 AJ EVAALAWA . Phone yew. Contractor's Name L:` a ense No. Phone TYPE OF WELL/PUMP WORK: NEW WELLSYSLL REPLACEMENT T DESTRUCTION ❑ r PUMP INSTALLATION TEM REPAIR OTHER �� 5 DISTANCE TO NEAREST: SEPTIC TANICror SEWER LINES DISPCSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indus ial ❑ Dpen om F7 Manteca Dia, of Well Excavation / omestic/Private P<ravel Pack ❑ Tracy Dia, of Well Casing 047 II ❑ Public ❑ Other Delta Type of Casing S LIrrigation Approx. Eastern i{ [ Cathodic Protection Depth Specifications Depth of Grout Seal [—I Geophysical r 1 ❑Other Type of Grout W10 NtPAIF a •//1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Donef�� L Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (11 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 O Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 7) Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED Distance to "nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 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 become subject to workman compensation laws of California." Contractor's hiring or sub- ntrac ing signature certifies the following: "I certify that in the performance of the work 'r which this permit is M�sr a e y per ns subject to workman's compensation laws of California."The applican f 1 e pections. Complete )P_engr v s si e. I Signed X Title: �� -+ . Date: krl FOR DEPARTMENT USE ONLY Application Accepted by 497029Area l"�L 41-1-S'�/ 21Stk 466-67 � Additional Comments: E] Lodi 369-3621 II Pit or Grout Inspection by Date U Manteca 823-7104 i Final Inspection by t- Date. rl(/ Tracy 835-6385 Applicant Return all copies to: . Environmental Health Permit/Services 1601 E. Hazel otn Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO $L1 r 39 J-5- w EH 13-24 REV. 10/82 � 00 14-26 f