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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466_6781 DATE ISSUED ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (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 the San Joaquin Local Health District. W Job Address d� l /GL1 y Subdivision Name Owner's Name Address 94ff14 Phone a Contractor's NameJ _MOVq 9WVW�D License No. 642,< 17G Phone y&r-3971 �. I TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-1 DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing 1-1 Public F-1 Other Deltas Type of Casing Lj Irrigation Approx. E] Eastern" Depth Specifications F-1CathodicProtection p Depth of Grout Seal I �Geophysical U Other Type of Grout Surface Seal Installed by F Repair Work Done [:] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') 4 Depth Filler Material (Below 50') n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A,P�ON �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 °Z. 'Lot size SO X 130 Character of soil to a depth of 3 feet: e-1-d;/ Water table depth SEPTIC TANK Type/Mfg {. �t1L� Capacity 17-&r�q No. Compartments 2— PKG. PKG. TREATMENT PLT. Type/Mfg - Capacity Method of Disposal SEWAGE SYSTEM 1—� Distance to nearest: Well Foundation �E? o Property.Line DESTRUCTION C-1 LEACHING LINE Jill No. & Length of lines — �A' Total length/size ! X 7 o FILTER BED Distance to nearest: Well Foundation -7.,C7 Property Line SEEPAGE PITS Depth �/�' Size °� Number 1 SUMPS Distance to nearest: Well Foundation 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 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 employ persons subject to workman's compensation laws of California." The applicant must call for all required i pections. Complete drawing on reverse side. j Signed X $ Title: Date: 7 Z,/—JO-3 OR DEPARTME Application Accepted b Area Q �j Stk 466-6781 Additional Comment Lodi 369-3621 Pit or Grout Inspection by Date `oZO 3 Manteca 823-7104 Final Inspection by Date l.$3 Tracy 835-6385 Applicant - Return all copies t nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO JJ� 221 EH 13-24 REV. 10/82wZ�j � 10/82 500 i 14-26