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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT , tJ �] Jr 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT N0. b f Telephone (209) 466-6781 DATE ISSUED 2d�J PERMIT EXPIRES -1 -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 f the'San Joaquin Local Health District: Job Address Y Subdivision Name Owner's Name Address Phone Contractor's Name License No. _� Z 7--2--,1, Phone 510 r— TYPE OF WELL/PUMP WORK: NEWIWELL' Q 'WELL REPLACEMENT ❑ 'PUMP INSTALLATION_.-.[_]'"'—SYSTEM"REPAIR �"`0 DISTANCE TO NEAREST: SEPTIC TANK L SEWER LINES FOUNDATION I AGRICULTURE WELL INTENDED USE 1-1 Industrial E] Domestic/Private E] Public F1 Irrigation '4 Cathodic Protection Geophysical } Other Repair Work Done .0 Well Destruction L TYPE OF:WELL PROBLEM AREA L)Open Bottom ❑ Manteca [] Gravel Pack F-] Tracy F-1 Other { flet t DESTRUCTION .,.OTHER — DISPOSAL FLO. PROP. LINE OTHER WELL PITS/SUMPS CONSTRUCTION SPECIFICATIONS Dia."of Well Excavation _ Dia, of Well Casing a Type of Casing Depth Approx. Eastern Specifications De s" Depth of Grout Seal Type of Grout Type of Pump Well Diameter Depth Surface Seal. Installed by H.P. State Work Done Sealing Material (top 501) Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW fNSTALLATION U PAl /ADDITION Lf (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: _L__ Number of b rooms Lot size X 12 Character of soil to a.depth�of 3 # Water table depth SEPTIC TANK [� TypeIMfg C[ Capacity oo No. Compartments Z— PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal { Distance to nearest: Well 5v Foundation ---`--fes Property Line 5 LEACHING LINE "No. & Length of lines L-% SCP Lr Total length/size O /5- FILTER 5FILTER BED Distance to nearest: Well Foundation L n Property Line SEEPAGE PITS Depth Z -S_ sizes i �� Number SUMPS L Distance_ to nearest: Wel I' Lia Lt -Foundation 1 Q 1,4— Property Line 5 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 rul.'es.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 is issued, I shall not employ any person in such manner as to -become subject to workman t 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 applica must cal or 1 required inspections. Complete drawing n verse side. Signed X Title: 1//� 1 f, _._. Date FOR.DEPARTMENT USE ONLY �� Appl' ation Accepted by Area Stk 466-6781 Additional Comments: lg Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies 'o: E ironmental-Health. Permit/Services 161511E. Aa/el o Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3N3 1X3_8 EH 13-24 REV. 10/82 10/82 500 14-26 1 D