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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N073 -Wo Telephore (209) 466-6781 ..pp DATE ISSUED p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , " (: . Application is hereby made to th'e'San Joaquin Local Health District fora 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 Subdivision Name 7 1C Owner's Name Address Phone -36(3- Contractor's 36(3-Contractor's Name License No. Phone O TYPE,OF WELL/PUMP_WORK: NEW WELL p WELL REPLACEMENT L] DESTRUCTION U k I PUMP INSTALLATION SYSTEM REPAIR OTHER U f DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES DISPOSAL FLO. § PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF- WELL T PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca pia. of Well Excavation U Domestic/Private Graveli'Pack ' Tracy Dia. of Well Casing Public b �jOther L E] Delta Type of Casing V Irrigation ° ApproxQ Eastern �' Specifications th D Cathodic Protection epDepth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work-Done [r Type'of`"Pump H.P. State Work Done r Well Destruction ❑ WellfD.iSealing Material�( op 50 ) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEWrINSTAL-LATION-X REPAIR/,ADDITION C,)' (-No..septlir tank or seepage pit permitted if public sewer is _a ' available within 200 feet.) Installation will serve: Residence Commercial Other tj Number of living units:s 'Number of bedrooms 1 Lot size 1 Water table depth Character of soil to a depthrof 3,feet: € SEPTIC TANK y :Type/Mfg C&C eft Capacity SOD No' Gompartments Q i `•'� Method of Disposal PKG. TREATMENT PLT. {� :Type/Mfg Capacity f Vl r�` SEWAGE SYSTEM y 1Distance to nearest: Well Foundation iD -- Property •L"ine DESTRUCTION #. ; LEACHING LINE F-1No. & Length of lines Total length/size a FILTER BED Lj :Distance,to nearest: Well Foundation Property Line. SEEPAGE PI_TS"';' � DePt �1, Size Number SUMPS e_DiYance�.to nearest: Well Foundation PropertylLine DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accord;nce with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin total Health District. E Home owner or licensed agent's sigriature�,certyfi,es..the,foll:owi.ng.:_"I,certify that in the performance of the work for which this permit is issued.._I-shall-not^eM oy any person in such manner as to become subj�'to'workman� compensation laws of California,"i -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,t6"workman's compensation laws of California.'. * 'a ;The applican ust callXS l r quired ' spec$i s. %�Complete_.drawin o reverse Signed X . MD Title: Date: a�� T USE ON Stk 466-6781 Application Accepted by Area � _� Additional Comments: ; Lodi 369-3621 Pit or Grout .Inspection by :w Y3 Date r�3a�?`.i, .-Manteca 823-7104 Final Inspection by #; Date �f-2 S/ �r3 L7Tracy 835-6385 95201 Applicant - Return all copies to:',l Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA FEE BASE AMOUNT DUE AMOJNT REMITTED RECEIVED BY p DATE "PERMIT N0. INFO gS �o f } �� 10182 500 i EH 13-24 REV. 10/82 14-26