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aei APPLICATION FOR PERMIT y SAN ]OAQLiN LOCAL HEALTH DISTRICT $3 1 3a 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 5C.�!6 Aa pa �" Telephone (209) 466-6781� 3 -- ger*`':. �y;'� DATE ]SSUEQ1 � / �� I y �� , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein \:,a described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump 1 and the Rules and Regulations of the San Joaquin Local Health District. Job Address ,f 6 ,� Subdivision Name ' Owner's Name �r �!. Address Jr hone y�$�~ 9 p ' ih �L4�s+I� License No. Phone ,�Coneractar s Name /lli, � i"s�'�� _ TYPE OF WELL/PUMP WORK: NEW WELL p WELL REPLACEMENT QESTRUCTION ' PUMP INSTALLATION SYSTEM REPAIR I OTHER LJ rr DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES --�� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial j' U open Bottom []Manteca Dia, of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing N Public F-1 Other Delta Type of Casing 100, G I �jirrigation Approx. Eastern Specifications DOPth ,:,„� �_ r t C4 Cathodic Protection ?, Depth of Grout Seal Z&/—/— 4 ❑Geophysical Type of Grout U Other .y / I Surface Seal Installed by Repair Work Done G Type of Pump _ _H.P. ! State Work Done Well Destruction U Well Diameter+ Sealing Material {top 501} Depth Filler Material (Below 501 Ij fh ' TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is i available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units Number of.bedrooms Lot size Character of soil to a. depth of 3 feet: Water table depth SEPTIC TANK Ej . Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal �E SEWAGE SYSTEM Distance to nearest: Well �Foundation Property Line DESTRUCTION Q LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance tc nearest: Well Foundation' Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Lj Distance to nearest: Well s Foundation Property Line_ DISPOSAL PONDS ._ I hereby certify that I have prepared this 7ppli,a60n•and thatrthe work will,be done in accordance wit San Joaquin county ordinances,.state laws,i�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 1 permit is issued, I sha:hl not employ any person--n,such manner as to become 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, II shall employ persons subject to workman's compensation laws of California." The applicant must calti f all r uir d inspections. Complete drawl on reverse side. Signed X Title: Date: %i 9�FPARTMDPET USE ONLY �z �Stk 6-6781 Application cepted by /�/� Area 1 ` - Lodi 369-3621 Additional comments: Manteca 623-7104 Pit or Grout Inspection y Date /Z'S I Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return alljcopies o.. E4rr. ntal Health Permit/Services 1601 E. H zel on Ave., P.O. Box 2009, St k., CA 95201 FEE BASE I�: AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. ' INFO ��3��., u d D j 10/82 500 EH 13-24 REV. 10/82: . 14-26