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APPLICATION FOR PERMITS SAN JOAQUIN LOCAL HEALTH DISTRIC,, w 1601 E. HAZELTON AVE., STOCKTON, CA J U L 2 4 1984 PERMIT NO. Telephone (209) 456-6781 r - ;, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (_. 04, LOCA TE ISSUED {Complete in Triplicate} i 140 4 '��I C� �""�� I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein41-v4Ad # described. This application is made in compliance with San Joaquin County Ordinance No. 549 for'sewage or No. 1862 for well/pump ;311fyh and the Rules.and Regulations of the 'San Joaquin LL•ocal. Health District. [�A � Job Address 1�3 Subdivision Name �//� r�Z_ Q� Owner's Name Address _r Phone Contractor's Name License No. Phone TYPE OF WELL/PUMA WORK: NEW WELL ❑ WELL REPLACEMENT F_� DESTRUCTION ❑ PUMP INSTALLATION SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS Industrial �i U Dpen Bottom. Manteca_ Dia. of We!!EExcavation w= Domestic%Private Gravel Pack ❑ Tracy Dia. of Well Casing lhPublic !' Other ❑ Delta Li Irrigation Type of Casing 9 Approx. Eastern Specifications ' Cathodic Protection Depth p Depth of Grout Seal Geophysical ❑Other 's �,•� Type of Grout �.�[✓� Surface Seal Installed by Repair Work Done ❑ Type of Pump � : H.P, State Work Done f Well Destruction U Well 'Diameter Sealing Material (top 501) _ Lu 3 Depth Filler Material (Below 50') 4 TYPE OF SEPTIC WORK: NEW `INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is '. available within 200 feet.) Installation will server Residence _ Commercial Other Number of living units: Number of bedrooms Lot size F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ;Type/Mfg Capacity No. Compartments C PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal 1� SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line I y DESTRUCTION ❑ (� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number SUMPS:. --Distance,to:.nearest: _-Well �.Foundation Property�Line-�'� — T 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 fo`r which this permit is issued, I shall not employ any person in such manner as to become subject to workman1s 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 st ca for allequir d - pec-tions. Complete drawing on reVer a ide, Signed Title: Date: R ARTMENT USE LY � Application Accepted by Area /" I 'Stk 466-6781 Additional Comments' j� Lodi 369-3621 S Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection byl: Date ❑ Tracy 835-6385 Applicant --Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED , RECEIVED BY DATE PERMIT NO. INFO %LI` FH 13-24 REV 0/82 7holy ps ".0— vele 4 li Ah t � N/'�`��10/82 500 �fi✓j1►+G�[ 14-26 � HK /LJ�1'rtiyc�t . AAA--A-- 2—