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APPLICATION FOR PERT T SAN JOAQLIN LOCAL H;7�.LTH DISTRICT 16GI E. lephone (209)'465-6791 209., STOCKT1 CA PERMIT N0. � � 1� Telephone {204) 466-6781 YEAR FROM DATE ISSUED PERMIT EXPIRES I YEDATE ISSUED { -}'7 _9t1 � 1 (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 Sar.Joaauin Local Health District. Job Address f f % ubdivision Name Owner's Name —, Address Contractor's Name uLI S License No. 8 rZ Phone TYPE OF WELL/PUMP WORK: NEW WELL EJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION { AGRICULTURE WELL OTHER, WELL PITS/SUMPS INTENDED USE TYPE OF WELL ,..�PROBLEM AREA CONSTRUCTION SPECIFICATIONS !_J Industrial U Openn Bottom-� :] Manteca Dia. of Well Excavation _ U Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing , Public Other E] Delta irrigation Type of Casing U/ Approx. Eastern Cathodic Protection Depth Specifications s' 1-1 Geophysical . Depth of Grout Seal , U Other Type of Grout Surface Seal Installed by- Repair Work Done Type of Pum 1, H.P. 1 P State Work Done Well Destruction U Well Diameters Sealing Material (top 50') i ,.Depth Filler Material (Below 50') ! f r TYPE OF SEPTICTWORK: ;NEW INSTALLATION ❑ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) [nsiallation)will serve : -Residence ; Commercial _ Other Number of:IiVing units: {• Number of bedrooms_ Lot size Character3 of-soil to a-depth of35 feet: Water table depth ,'j SEPTIC TANK_ &j- ' Type/Mfg , Capac,i�ty �� No. Compartments 42 PKC. TR'EATM'ENT' PLT:, ; Type/Mfg Capacity = Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundations_ Property Line S DESTRUCTION ; D;� ', � - 8 LEACHING LNo. & Length of lines` +� y ,. LI � 9 Total Length/size d � FILTER BED w KA Distance to nearest: Well S�2 f�Foundation Property Line S FT SEEPAGE PITS' r"'; ��j'_ pepth '$�. b Size Number ; SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PON S, +. y I hereby certify that I have prepared this'aipplicat.ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of'tfie'-San--doaguin=Local Health District. Home owner or licensed agent's signature certifies the following: "I'certify that"in"tfie-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 applicant must cal, for 11 r uired inspectionsS•tomplete drawing on reverse side. Signed X r lo Title: _ _ Date: FOS QLPARTMENT USE ONLY r t I Application Accepted ,by � �- ...� Area 3 Stk 466-6781 ' Additional Comments: Y� [� Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection byDate L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. EH 13-24 REV. 10/82 _x 10/82 500 14-26 } r