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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S '_ Telephone (209) 466-6781 - - DATE ISSUED � b—13—T4 PERM-Ii EXPIRES I YEAR FROM DATE ISSUED (CoM, fete ir. Triplicate) -Application is hereby rade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is grade 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 3istrict. Job AddresslY _Subdivision Name Owner's Name Address Contractor's Name ' License No. Phone _...__ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PMP INSTALLATION y� SYSTEM REPAIR OTHER I ) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSALL FLO. PROP. LINE FOUNDATION AGRICLLTL'RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL PROBLEM AREA CONSMCT13N SPECIFICATIONS 0 Industrial (J Open Bottom Cl Manteca Dia. of Well Excavation _ L_!Domestic/Private [j Gravel Pack Tracy Dia. of Well CasingSi L3 Public [ Other Delta Type of Casing W L�2irrigation Approx. Eastern Specifications _ V1 FiCathodic Protection Depth Depth of Grout Seal �.. _ ... Geophysical r a Type of Grout U Other Surface Seal Installed by Repair Work Done E] Type of Punp ;.P. State Work Done a Well Destruction r-1 Well Diameter Sealing Material (top 501) _ . .... Depth _ Filler Material (Below 50') .r✓ TYPE OF SEPTIC WORK. NEW INSTALLATION v REPAiP4ADOITION L f (No septic tank or seepage pit Permitted if public sewer is !✓ �• available within 200 feet.) Installation will serve: Residence ZCommercial other Number of living units: .,, Number of bedrooms Lot size Character of soil to a depth on 3 feet: ., water table depth SEPTIC TANK [H' Type/Mfg �—•- y ' Capacity Q NO. CompartmWts _ ,w - -, , PKG. TREATMENT PLT, 0 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c Distance to nearest: Well D. Foundation Property Line DESTRUCTION T LEACHING LINE t_ No. a Length of lines _ , Total length/size -" t" _...� FILTER RED Cj Distance to nearest: Weil � FoundationdJt•Property fine SEEPAGE P17S r Depth T Size _ Number SUMPS j Distance to nearest: Well foundation Property Line DISPOSAL PONDS Ci I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Zoaquin Local Wealth District. Harm owner or licensed agent's signature certifies the ,following: ": 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*,comspensatien laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that 'n 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 NO call�for all r 50 red inspections. Complete drawing on reverse side. Signed X___ �'y F aevG�� '� _ Title: J _ ._ Date:Ifil .r�.�. .. ARTidENT USE {IDILY Area Sik 456-6781 Application Accepted by jZZ, 5I.C11=44 — Additional Corrents: it _ Lodi 369-3621 i Pit or Grout Inspection by .__ _ _Date _ l.i ':Manteca 823-71.04 Final Inspection oy �"r 1 � ate y' ''� / r Tracy 9, t385 Applicant - Return all copies to: Environmental .th Permit/Services 1601 E. Haze!tor. AvA fo.o. Box 2009, Sk:, CA 9520: FEE ( BASE AMOUNT DUE AMOUNT 0E*ITTED -- - R£CEDIED BY DATE PERMIT ND. INFO D. 13-24 REV. 10/82 0182 503 14-26