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APPLICATION FOR PERMIT # SAN JOAQUIN LOCAL HEALTH DISTRICT 93-140 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUE J �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) 3 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 L calpHeealltb,District. Job Address r©7 C� c:�n- SS,bdivision Name Owner's Name:• .�•�� +'+' Address Ea Phone Lantractor's�Name aT r� License No, / Phone _h k W TYPE OF WELL PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION �} j PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER LJ DISTANCE TOlNEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial F-1openBottom Manteca Dia. of Well Excavation U Domestic)Private Gravel Pack [:]Tracy Dia. of Well Casing ❑ Public [ Other [ Delta Type of Casing V Irrigation Approx. [] Eastern Specifications [Ca thodicProtection Depth Depth of Grout Seal [ Geophysical Type of Grout Other } U Surface Seal Installed by Repair Work Done G Type of Pump H.P. State Work Done Well Destruction [ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Li REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is .1 9 available within 200 feet.) Installatlion will serve: Residence r/ Commercial Other Number o.1 living units: _/__ Number of bedrooms � Lot size Character, of soil to a depth of 3 feet Water table depth SEPTIC TANK [j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line _ t DESTRUCTION 01 LEACHING LINE No. & Length of lines _�-^ ']d Total length/size FILTER BEDS [. Distance to nearest; Well Foundation 5-f Property Line 71- 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.ior licensed agent's signature certifies the fol lowing: "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-contracting signature certifies the following: "I certify that in the performance of the work for which this permil�t is 'slued, I shall employ persons subject to workman's compensation laws of California." The applic;, m t for b require 'ns p ions. Complete drawing on reverse side. Date Signed X Title: i F DEPARTMENT USE ONLY �Stk 466-6781 Application Accepted by Area 0 Sr Adjitional Comments: Lodi 369-3621 I, Pit or Grout Inspectio b Date r3 [ Manteca 823-7104 Final Inspection by Lltor� Date �_ / iii L Tracy 835-6385 Applicant- Return all copie o: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEF'l BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 1 3 i i G 10/82 500 EH 13-24REV. 10/82 y 14-26'3 3