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{ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXP1R£S 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. r 7 DATE ISSUED 'Z - Application Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work: herein' BASE described.-. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump AMOUNT REMITTED ij,,. RECEIVED BY DATE PERMIT N0. and the Rules and Regu]ations of theSan Joaquin Local Health District. Job Address LASubdivision Name '- x" Owner's Name Address Phone Contractor's Name LEE, I License No. 24 Phone 3 TYPE OF WELL/PUMP WORK: NEW WELL 'EJ WELL REPLACEMENT_' Q-+_ JESTRUET,40N.0 --� PUMP INSTALLATION SYSTEM REPAIR L7OTHER -� r n ,_ ) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDEb USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industria] ❑ Open Bottom Manteca Dia. of Well Excavation .' ._._0 Ddmestic/privat"e" " __ ��ravel`�ack—�[]iracy r Dia. of Wel] Casing 1-1 Public Other Delta pe of Casing U Irrigation Approx. E] Eastern F 1:1y Specifications Depth 4.. Cathodic Protection" p Depth of Grout Seal j� Geophysical Type of Grout (J Other / ;6� 1-'f Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') fQ TYPE OF SEPTIC WORK: NEW .INSTALLATION U REPAIR/ADDITION(No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other R Number of living units: Number of bedrooms Lot size „c o� G Character of soil to a depth of 3 feet: Water. table depth SEPTIC TANK Type/Mfg CC Capacity No.. No..Compartments 71 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of bis sal Distance to nearest: Well Foundation Property Line 3 T LEACHING LINE ki No. & Length of lines 4 Total length/size V FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS [] Depth Size Number SUMPS U ,k Distance to nearest: Well Foundation Property Line: DISPOSAL PONDS s " r I hereby certify that I have prepared this application and that the work wil9,be done in accordance riith 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 workmant compensation laws of California." Co ractor's hiring or sub -contracting signature certifies ..the following. "I certify that in the performance of the work for which this- mit is issu I sha 1, employ persons subject to workman's compensation laws of California." The applica s c 1 r`qu' d.{inspections: Completed wing a reverse ide. < a Signed Title: ! r.{ Date: �j FEPA ENT USE ONLY Application Accepted by (�, Ar Stk. 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout inspection by ��-� — Manteca 823-7104 Final Inspection by - Tracy 835-6385 Applicant - Return all c es Environmental. ealth Permit/Services 1601 E. Haze ton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED ij,,. RECEIVED BY DATE PERMIT N0. INFO '- x" I 3 EH 13-24 REV. 10/62 ry, C 14-26 f IO/82 500 Q0 �C�