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f APPLICATION FOR PERMIT \/D rA f� !✓ SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. -HAZELTON AVE., STOLKTON, CA PER"i1T rv0. 03 G p ods-- Telephone (209) 466-6781 DATE ISSUED pf PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED (Complete in Triplicate).' 'r 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 mage 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. Job Address ��esSubdivision..Name �7 - .Si'li2t_!P Phone Owner's Nam �' L — Address 66=9A2 y bntra ttor'S Name �,�� License No. _�,��(^35/3 Phone rl TYPE OF WELL/PUMP,IWORK: NEW WELL F-1WELL REPLACEMENT ❑ DESTRUCTION EJ — ` PUMP. INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCO. 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 i ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing 1 ❑ Publ is ❑Other ❑Del to Type of Casing 4 ❑ Irrigation . Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Y :l s Type of Grout ❑Other Surface Seal Installed by s Repair Work Done Type of Pump H.p. State York Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTAL`ATION REPAIR/ADDITION ❑ (No septic tank or seepage piavallaitted thi if public fsewe) is 1 Installation will server Residence .Y Commercial _ Other Number of living units: � Number of bedrooms _Lot sf ze ^C/ / Water table depth, 00 Character of soil to a depth of 3 feet: C"'� ( SEPTIC TANK W, "Type/Mfg g r ^ 4rsxaC Capacity /Z 20 No. Compartments 'Z ` 1p� Method of Disposal PKG. TREATMENT PLT. E] Type/qfg Capacity SEWAGE SYSTEM Distance to nearest: Well, 00 Foundation is __ Property Line DESTRUCTION • .1 ( LEACHING LINE No. b Length of lines Z 8J' Total length/size /'70 X 2 FILTER BED ❑ Distance to nearest: kelt /00 Foundation Property Line SEEPAGE PITS ® , Depth! _ Size q Number 9 — If(. SUMPS ❑ Distance to nearest: Well ��'• Foundation Property Line I. DISPOSAL PONDS ;. 1 hereby certify that I have prl;pared this application and that the work will be done in accordance with San Joaquin county l ordinances, state laws, and H.. rand regulations of the San Joaquin Local Health District. ` ordinances or licensed a gent�ak s'gnature certifies the following: "I certify that in the performance of the work for which this Home permit is issued, I shall nol�emp1 dy'any person in.such manner as to become subject to workment compensation laws of California." Contractor's hiring or sub-cgntragting+signature certifies the following: "1 crmance of the work for which ertify that in the perfo this permit is issued, I shald�emdlby persons subject to workman's compensation laws of California." The applicant must fall f al r equir in actions. Complete drawm�g7 on reverse side. g_7 — Date: Sign Title ed % • � i 1, EPARTMEN7 USE,ONLY` Area ®Lodi 369-3621 Application Accepted by��.. Additional Comments: .;^�-.r` Pit or Grout Inspection' by ' �'' _ Date �^ Manteca 823-7104 . `�� Data o ❑ Tracy 835-6385 f Final Inspection by P.O. Box 2009, Stk., LA 95201 Applicant - Return all copies to- IjEnvironmental H alth mit/Services 1601 E. Hazelton Ave., FEE I BASE AMOUNT DUE, AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. I INFO °l 1 3 83 R 7 7 • 10/82 500 t �. EM 1 3 _29 REV. 10/92 T .