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APPLICATION FOR PERMIT JOAQUTO�M , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT N0. Telephone (209) 466-6781 ' .PERMIT EXPIRES 1 YEAR FROM DATE'I5SUED 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 1 described. This application is made in compliance with San Joaquin County Ordinance No. 544 for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. N Job Address Eitd Road (350O W.Blewett) Subdivision Name " Owner's Name Robert H.: -Brown, Sr . Address874 E. Woodward;Manteca Phone (209) 239-4-92 % Contractor's Name SELF License No. z Phone 3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER [] DISTANCE TO NEAREST: SEPTIC TANK _ �f SEWER LINES. - DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,'WELL PROBLEM AREA ��" ijCONSTRUCTION.SPECIFIGATI0N5 � - ; Industrial ❑Open Bottom ❑Manteca Dia_ of Well Excavation r U Domestic/Private ❑Gravel\Pack; --[-]Tracy'•----- -Well Casing _44-.. ❑Public ❑Other ❑Delta ' Type of Casing V�! Irrigation Approx. ❑Eastern ' ; ❑ Specifications Cathodic Protection Depth ' Depth of Grout Seal ❑Geophysical - ❑Other Type of Grout Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) f Depth Filler Materiali(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION-i ,. i f , 1 ! (NG septic tank or seepage pit permitted if public sewer is 9 available within 200 feet.) Installation will serve: Residence XX Commercial _ Other i A Number of living units: Z-- Number of bedrooms 2' t Lot size 40 a ere s Character of soil to a depth of 3'feet:.; 7-ta.vellyTLo's Robles IoaWvter-table depth �+ SEPT k TANK ED Type/Mfg ��n t_ _ Capacity 2 0 0 0 No. Compartments .f y PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE•.SYSTEM Distapce to nearest:' Well Foundation DESTRUCTION ❑ t-t l ��a Property Line 3.00 a r LEACHING LINE No, s Length of.;lines i_n I Total length/size 15 0 1 FILTER BED ❑ Distance to nearest': Well I Foundation Property Line r SEEPAGE PITS ��j Depth Sizeb Number SUMPS [J- Distance to nearest:- Nell- Foundation Property Line DISPOSAL PONOS ❑ YN _-ANA I hereby certify that I have prepared th'is'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 l permit is issued, I.shal7,not.employ any'e son-in-.such-manner as_.to.-hecome.subject-to workman�compensation.laws of Cal.ifornia.'.'. Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is ssued. I shall employ persons subject to workman's compensation laws of California." The applicanyxust callFes' equir inspections. Complete drawing on reverse side. Signed X Title: Secretary Date: 10-28-86 R DEPARTMENT USE ONLY f/ Application Accepted by -,- r rea ❑ Stk 466-6781 Additional Comments: ' �- L �`J'�2 �/� � GYfI�?� ❑ Lodi 369-3621 Pit or Grout Inspection br r to ❑ Manteca 823-7104 Final Inspection by _ /ays� Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmen a Health Permit/Services 16D1E. Hazelton Ave., P.O. Box 2009, Stk.. CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFD 0 �� 46' L47- �sb-i `7 EH 13-24 REV, 10/82 q{Ty(a 10/82 500 14-26 y