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I APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT I601 E. HAIELTON AVE_, STOCKTON, CA Telephone (209) 466-6781 PERMIT NO. PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED DATE ISSUED q 3-8 -8 y (Complete in Triplicate) J Application is herebya •I the f described. This applicationoishmade ninocompliance lwith lSan th DJoaquin Count istrict for a p0 dinancee,,iit to cNo. 549tfor dsewage sorlNo.- 1862rfor ewell/ um and the Rules and Regulations of the San Joaquin Local Health District. =x, Job Address p p Subdivision Name Owner's Namey,.� Ey Address - Contractor's Name P8� �Ayc Rc Tree Phone '�' i51ir/fie+ y 5'01Y License No, yyy.8�� Phone .VWY- TYPE OF WELL/PUMP 'WORK: NEW WELL [j WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ S.0 T•EM REPAIR ❑ OTHER Q16 DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE [NTENOEO USE FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS TYPE OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICATIONS l Industrial U Open Bottom L! Domestic/Private Cl Manteca Dia. of 'Well'Excavation Gravel Pack Tracy Dia. of Well Casing ( ` 17 Public [j-Other Delta Lj Irrigation Type of-&-ing Approx. Eastern i t Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal LJ Other Type of Grout } Repair Work Done MType of Pump H.P. Surface Seal Installed by _ State Work Done Well Destruction [l Well Diameter 1 Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION 1j (No septic tank or seepage pit permitted if public sewer is Installation will serve: ResidenceX - Commercial Other available within 200 feet.) _ Number of living units: / Number of bedrooms _" Lot size / &C_xe S Character of soil to a depth of 3 feet: !,ofyry Water table depth �r SEPTIC TANK G Type/Mfg A'd' C Capacity /900 P y . -No. Compartments _ ' X PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ��--11 Distance to nearest: Well ,90 Foundation. -R S Property Line >ye.,� DESTRUCTION U LEACHING LINE No. & Length of lines a7 - `y0' Total length/size .2 �_v FILTER BED Distance to nearest: WellFoFoundation `!D �_ ., Property Line ;W S SEEPAGE PITS Cf Depth + Size Number r SUMPS U Distance to nearest: Well Foundation a Property Line DISPOSAL PONDS CI I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county 1 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 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 applicant mus tail fora 1 required inspections. Complete drawing on reverse side. ! Signed Title Date: 3►4 4' FOR EP ENT t ONLY Application Accepted by Area Stk 466-6781 Additional Comments: (] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Date .� Final Inspection by CSI Tracy 835-6385 Applicant - Return all copies to: Environm ntal H lth Permit/Services 1601 E. H zelton Ave., P.0, Box 2004, St k., CA 95201 FEE BASE AMOUNT DUE x AMOUNT REMITTED RECEIVED BY DATE PERMIT NO INFO Ill' 4-3--iq I lq EH 13-24 REV. 10/82 14-26 10/82 560