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APPLICATION F0 LT Y�� SAN JOP.C�Ui1, LOCA:. IiEALTHTH DISTRICT _ 1.601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 �2 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM PATE 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 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 Regulatio s of t e San Joaquin Local Health District, Job Address Xfubdivision Name Owner's Name Address �L Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ G� 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 �1 F-1 Industrial U Open Bottom [] Manteca Dia. of Well Excavation >S ❑ Domestic/Private ❑ Gravel Pack F-jTracy Dia. of Well Casing ❑ Public CJ Other ❑ Delta T Irrigation Approx. ❑ Eastern yof Casing F-1CathodicProtection Depth Specifications ifications Depth of Grout Seal ❑ Geophysical � U Other Type of Grout Surface Seal Installed by Repair Work Done ❑ 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 U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is __ _ _availsla].e�,i.ti�.inlflOA,feet_-}.. Installation will serve: Residence L Commercial _ Other Number of living units: Number of bedrooms Lot size ,�� LL/IiL7 Character of sail to depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [! Type/Mfg Capacity - ' 'Method of Disposal SEWAGE SYSTEM Distance to nearest: WellO Foundation Property Line �4— DESTRUCTION ❑ LEACHING LINE T No. & Length of lines — q0 Lr Total length/size �QQ Lt— FILTER BED ❑ Distance to nearest: Well oundation Property Line p SEEPAGE PITS Eel" Depth -2 5 Lt Size p 4-27: if Number .3 SUMPS IJ Distance to nearest: Wel l Q 11 ��Foundation h l ,� Property Line -17 DISPOSAL PONDS �c�r- ` 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 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 the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applican ust cal f 1 re uir inspections. Complete drawing on reverse side. Signed X Title: _ (per Date: �CJ1:7��3- FO PARTMENT USE ONLY Application Accepted by� Area Stk 466-6781 Additional Comments Lodi 21 cue I Pit or Grout Inspection b Date Manteca 823-7104 `�� Final Inspection by DateQi� ❑ Tracy 835-6385 Applicant - Return all copiesi : Environmental Hea th Permit/Services 6011 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 0', k0--1��3.3 g3-11S�0 I EH 13-24 REV. 10/82 10/82 500 14-26