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C i APPLICATION FOR PERN,1. - j SP.N JOAQUiN LOCAL H ALTH 3 STRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. p q—U Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUE (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 Regul ions of the Sa Joaquin Loc alIt District. Job Address division Name Owner's Name .�°� s� S Phone� w��7" 3 Contractor's Name / / License No. Phone �d� } TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial ❑ Open Bottom ❑Manteca Dia, of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Public ❑Other ❑ Delta Lj Irrigation Approx. Eastern Type of Casing Cathodic Protection Depth Specifications C7 Geopl4ysical, Depth of Grout seal ❑Other Type of Grout 1 Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') j TYPE OF SEPTIC WORK: NEW INSTALLATION ^�j� ..REPAIR/ADDITION U, (No septic tank or seepage pit permitted if public sewer is X. available within 200 feet.). Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: I Water table depth 40 SEPTIC TANKType/Mfg L.�ISI _- pLb� capacity /f ,� No. Compartments - PKG. TREATMENT PLT. Type/Mfg Capacity ~ Method of Disposal SEWAGE SYSTEM Distance to nearest: Well $Foundation 32)4 Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines 9 Total length size FILTER BED E] Distance to nearest; Well�7 Foundation L9)D a -4L- Property Line /aQ r SEEPAGE PITS Deptha Size .� f�. Number _7__ SUMPS L J Distance to nearest: Well ( ,. Foundation 1 Jr,A_ 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 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 permit i`s issuel, I shall not employ any erson in such manner as to become subject to workman compensation laws of California." Contractdr's ing or sub-contractin nature certifies the following: "I certify that in the performance of the work for which this permit ' issued, I shall emplo rsons subject to workman's compensation laws of California." The applic a.11 f all re ed ins ,tions.,_ Lomple dra 'n�ornrev�erseside. Signed Title: Date: Application Accepted by �1�� fr RT 11T�US�E ONLY a.; A ea C 4 ❑ Stk 466-fi7B1 Additional Comments: r Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by _ Date L1Yracy 835-6385 Applicant - Return all copies to: - Envi mental Health Permit/ ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE A,m6UNT REMITTED RECEIVED BY DATEPERMIT NO. INFO 5� EH 13-24 REV. 10/82 10/82 500 �. 14-26 !Fi