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APPLICATION FOR PERMIT Ll� ? SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON /��,AVE., STOCKTON, CA 1T" `w� PERMIT N0. Telephone (209) 466-6781 .3X%QU V LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED H LTH DISTRICT (Complete in Triplicate) � 1 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 Regi i tions of the San Joaquin Local Health District. Job Address Cal NLk.As W Subdivision Name Owner's Name L Address (NJ_(��Op( _-_ n Phon Sot q-- '3 Contractor's Name SX2 License No. Phone 1 ^� ; TYPE OF WELL./PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ U,) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' 17 Industrial C'[j_Open Bottom Manteca a T Dia. of Well Excavation ! I U Domestic/Private ❑'Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [j Other ❑ Delta � Type of Casing i G Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work.Done. Well Destruction ❑ Well Diameter Sealing Material (top 50') _ 4- Depth Depth Filler Material (Below 50') � J TYPE OF SEPTIC WORK: NEW INSTALLATION E) REPAIR/ADDITION )( (No septic tank-or-seepage-pit permitted if public sewer is q "� available within 200 feet.) ' Installation will serve: Residence _k_1 Commercial Other Number of living units: �_ Number off bedrooms 3 Lot size_ZQ 4_(. } Character of soil to a depth of 3 feet: _ 1N� - Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity -^--No. Compartments PKG.~TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: 'y Well Foundation property Line \ DESTRUCTION ❑ -• LE�C'HEING LINE U �No. &.Length of lines. h• Total length/size t FILTER BED ❑ Distance to nearest: Well" oundation Property Line SEEpA E PITS Cj Depth Size Number SUMPS r„F�, -❑I -.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. r 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-contracting signature certifies the following: "I certify that in the performance of thework for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must ll for all required inspections. Complete drawing on reverse side. Signed X 1i Title: ipAe. - nate: F PARTMENT USE ONLY O ❑ - Application Accepted by Area Stk .466-6781 .4� Rdditional`�Comments: Lodi 369-3.621 a Pit or Grout Inspection by Date �z �jManteca 823-7104 -f Final Inspection by DateTracy 835-6385 Applicant - Return all copies to: Environmental th Permit/Services 1601 E. Hazelton Ave., P..0. Box 2009, St k., CA '95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY OAT 1 PERMIT NO: .� INFO Y 1'0/82 500 EH 13-24 REV. 10/82 14-26 - t•