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v APPLICATION FOR PERMi- `J SAN EOF06;.'; LOCALAVE.,ACTH CKTON,C 1601 E. HAffLTON AVE. STUC KTON, CA PERMIT N0. Telephone (209) 466-6781 - DATE ISSUED 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 donstruct 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 andRegulations of the San Joaquin Local Health District. Job Address 3- / 2 /�,/J/iNFbK� Subdivision Name Owner's Name I&, // /,?,q C/<&9e Address S"4„-P Phone Contractor's Name License No. ::Z 3 Phone W TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR L7 OTHER [_J 1 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 Industrial Open Bottom Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of-Well Casing ❑ Public ❑Other E]Delta Type of Casing L Irrigation Approx. EJ Eastern M Cathodic Protection Depth Specifications ` Depth of Grout Seal E Geophysical TypeGrout L Other p,y Surfaccee Seal Installed by Repair Work Done M Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION N (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms 13 Lot size Character of soil to a depth of 3 feet: C Water table depth fio SEPTIC TANK K T c7 Type/Mfg r .'NK,Q t,sd[ Capacity /2 0o No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines 'y0 v Total length/size '/ 7 V 11 X __ FILTER BED Distance to nearest: Well /O a Foundation Property Line -- SEEPAGE PITS Depth Zs Size `-3 3 Number SUMPS ❑ Distance to nearest: Well /o cT Foundation Property Line 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'aa 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 applicant must c 1 for �aYll.,)requi d instep/fictions. Complete drawing on reverse e. Signed Xlll- C.,FC,�J' ab•°�«„f-f.,_ Title: CJ -71z Date: 44 PARTM O USE Or LS 6'f S ❑ Application Accepted by (q / j'z"rr.,.-//Ca Area 6 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by - Oa to "f��j_=_� ? pl ❑ Tracy .835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY I DATE Il PERMIT NO. INFO LA � Jam IJ �7MI r EH 13-24 REV. 10/82 10/82 500 14-26