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�- _ APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. i Telephone (209) 466-6781 11 I DATE [SsuE3jI-;t-! PERMIT ExPIRfS I YEAR FROM 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 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 t e San Joaquin Local Health District. Jab Address /,>— Subdivision Name Owner's Name Address Phone Contractor's Name L ense No. e�7-21Phone Zx q-eqg fir/ I TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR OTHER DISTANCE TO NEAREST_ SEPTIC TANK SEWER LINES DISPOSAL ELI). PROP. LINE' S FOUNDATION AGRICULTURE WELL OTHER WELL ; J PITS/SUMPS + k INTENDED USE TYPE OF WELL PROBLEM AREA '' CONSTRUCTION SPECIFICATIONS q 4D-Indus.tr.ial,_- — pen Bottom O-Manteca: - Dia. of Well-,;Excavation,,r:..►-� U Domestic/Privatef Gravel Pack Tracy � i� Dia. of Well Casing Pub Other Delta V Type of Casing rrigation Approx. Eastern Specifications ' [�Cathodic,Protection Depth Depth of Grout Seal U Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction F-1 Well Diameter Sealing MaterialJ(top 50+) _ Depth Filler-Material (Below 50') l' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U. (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 Lot size lJ Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK Li TypefMfg Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: We�li Foundation Property Line DESTRUCTION_. Q LEACHING 111E LI No. &.Length.ofylities Total length/size FILTER BED. Distance to nearest:-- Well, Foundation Property Line SEEPAGE PI-TS Cj Depth Size Number SUMPS -` �{ Distance to nearest: Well _ Foundation Property Line D]SPOSL>PDNDS I hereby certify that I have prepared this application and that the work will he 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: "1 certify that in the performance of the work for which this i 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 loy persons subject to workman's compensation laws of California." The appli an st call for al qui r inspections. Complete dra.wi n e side r _ - Date: Signed x Tit1e:� FOR DE RTM T USE NL. is tion Accepted by Area kSodki 466-6781 Additional Comments: 369-3621 ' Pit or Grout Inspection b Date Manteca 823-7104 Final Inspectian by14 Tracy 835-6385 Jlppli.cant,.-.Retur.n,.a1J-4opies c,' Enviro. ental Health Permit/Services 16 1 E. Ha elton Ave., P.O. Box 2009, Stk., CA 95201 FEE_ --BASE-- AMOUNT..-DUE z,..- AMOUNT REMITTED 1,f.14ECEIVED,5Y __„.DATE__ PERMIT INFO I EH 13-24 REV. 10/82 10/82 500 a 14-26