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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT „(f 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. D J Telephone (209) 466-6781 DATE ISSUED EI -3= 3 PERMIT EXPIRES I 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 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, A Jab Address "ITubdivision Name Owner's Name J� U J, Address U }dLF ruCtmar�l� Ct Phone License No. _ Phone 2 Contractor's Name �` c TYPE OF WELL/PUMP WORK: NEWWELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y PROP. LINE SEWER LINES DI5POSAL FLD. ,} DISTANCE TO NEAREST: SEPTIC TANK � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial [J Open'Bottom ' ❑Manteca' ' _Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑Tracy •'Dia. of Well Casing ❑ Public Other ❑ Delta Type of Casing LjIrrigation Approx. ❑ Eastern Specifications Y ❑Cathodic Protection Depth Depth of Grout Seal I ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done E]'\ Type of Pump H,P. State Work Done Well Oestruction F-1Well Diameter, Sealing Material (top 50') Depth s Filler Material (Below 501) r No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION L� REPAIR/ADDITION ❑ ( P available within 200�feet:) fib. Installation will serve- Residence Commercial Other Number of living units: _.__ Number of bedrooms Lot size 1. Water table depth `J Character;of soil tb 3 depth'of 3 feet.: a ' e Mf + Capacity, No. Compartments SEPTIC.TANK iTyP / 9 `-17: Capacity Method of Disposal + T 4 PKG. TREATMENT PLT. ❑ Type/Mfg _. ; f1Well� x `Foundation 'A ' Property Line Di SEWAGE SYSTEM ❑ stance to nearer DESTRUCTION 9 +' No. & LengthSof-lines �p c1 Total length/size LEACHING LINE FILTER BED Distance to nearest: Well Foundation Property Line Depth Size .a'�_�� Number SEEPAGE PITS ❑ P - ��prop''erty Line V f SUMPS ❑� Distance to nearest: Well ^�i Foundation _ 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 or licensed agent's signature certifies the following. I certify"that in the performance of the work for which this permit is actorissued, I shall not employ any person in such iesmanner as to the followbecng-meIsubject to workmathecperformance ofompensation wthe fwork�for nwhich. _ I Contr 9 rt this permit ris issued, I shall employ persons subject to workman's compensation laws of California," r ` The applicant 'must c 1 fA 1 regi. red inspections. Complete drawing on reverse side, pate: i! 5igned`X� � �./ Title: FOR 0 PARTMENT USE ONLY 6� ❑ J K. Area 5tk 466-6781 I Application Accepted by ❑ Lodi 369-3621 Additional Comments: �1 4 Date L] Manteca 823-7104 � lPit or Grout Inspection'by w MM — -Date r PPS ❑ Tracy X835-6385 r Final Inspection by ' Applicant - Return all copies to: Envir ntal Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, St k., CA 95201 '} DATE PERMIT'N0. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY r M INFO _ O'a J ^� V"`g1� ;. 10/82 500 � EH 13-24 REV. 10/82 r 14-26