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5 _ I APPLICATION FOR PERMIT SAN JOAQUIN' LOCAL HEALTH DISTRICT , ti 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S9. � i Telephone (209) 466-6781 DATE ISSUED � � 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 Rulepps and R ulatio s of San Joaquin Local health District. Job Address-I E Subd' ision N me Owner's Name' E AddressVt Phone Contracto i� Name License No, IL Phone TYPE OF WELL WORK: NEW WELL ❑ WELL REPLACEMENT bQ_' DESTRUCTION ❑ - Do DISTANCE PUMP INSTALLATION r7 SYSTEM REPAIR ❑ O;THE7R'-'U'W-^�^�^ "a - + Do DISTANCE TOINEAREST: SEPTIC TANK SEWER LINES DISPOiAL FLO. PROP. LINE I' FOUNDATION AGRICULTURE WELL OTHERiWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open�Bottom ❑Manteca + Dia. of Well Excavation Domestic%Private Gravel `�~ TracI t� Dia, of Well +Casin LJ ❑ GL:❑+ y ,L_ { g ❑ Public ❑j Other x ❑ Delta T , ' Irrigation Type of Casing .aT Lj 9 Approx. ❑ Eastern Depth ^* Specifications3 Cathodic?Protection o --� t ❑ "�� '�.. Depth of Grout Seal Geophysical Type of GroutI OtherlneE] Surface Seal Installed by Repair Work Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i ? _ � E d� Depth Filler Material (Below 50') �., .., . . - I t ' �' .�. .... 1 TYPE OF SEPTIC'WORK: -NEW INSTALLATION �EPAIR/ADDITION ❑ (No sept it tank o Seepage pit, per mltteq-iT-pub`iic sewer available within 200.feet.) i Installation will serve: Residence Commercial _ Other Number of, living units: _/_ Number of bedrooms _ Lot size !- Character. of soil to a depth of 3 f t: '. .. Water table depth SEPTIC TANK Type/Mfg /l� �"�, % `_ •`Capaeity=, iQ t' No. Fompartments PKG. TREATM1:NT PLT. Type/Mfg Capacity MethA;�6f,Disposal I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ _ ' LEACHING LINE No, & Length of lines QZ Total length/size/740 FILTER BED �I ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS /+Depth Size T' ' Number i ifI SUMPS I L Distance to nearest: Well Foundation Property Line } ? DISPOSAL PONDS C �• .��-� �� T�� ` it i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I ordinances,11state laws, and rules and regulations of the San Joaquin Local Health District, t ( Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wor�kfor which this permit is Asued, I shall not employ any person in such manner as to become subject to workman-compensatioh,laws of California." Contractor'"s hiring or sub-contracting signature certifies the following I ce'rtify.-that:in the:perWrmance'of,*the work for which this permitllis issued, I shall employ persons subject to,wgrkman's comeensa.lon laws 6f• California," The applicant must call 11 required inspections. Complete,draWhg on reverse side. q Signed X In- Title: 4 Date: C�( �F !.. P TMEN F ONLY 2 AppQc9tion Accepted Area Stk 465-6761 Addiltional Comments: ❑ Lodi 369-3621 Pit `r Grout Inspection by Date Q f$3 ❑ Manteca 823-7104 Finclhl` Inspection by Date C -7 ❑ Tracy 835-6385 Applicant f Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 1� FEE i BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i INFOI EH 13-24 IREV. 10/82 (� 10/82 500 14-26 i ' 1 • I