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APPLICATION FOR PERMIT y-r SAN JDAQUiN LOCAL HEALTH 'DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT No. Q I , c! Telephone {209) 466-6781 a 4 GATE ]55UED��'V;1� 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 madft iance with San Joaq in County Ordinance No. 544 for sewage or No. 1862 for well/Pump i and the Ru es Re lattons of thyitnQL ea JBi �•� i Job Address ��1�YYRO'A-D� A CA Subdivision Name MAYORS MANOR PARK �I owner's Name �STO ON SERVICE CORBress P.O. BOX DRAWER "L" Phone . Contractor's Name ALLEN WAGGONER License No. 263644 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION i PUMP INSTALLATION SYSTEM REPAIR 0 OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYrE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS itD Industrial U Open Bottom E] Manteca Dia, of Well Excavation U Domestic/Private D Gravel pack ❑ Tracy Dia. of Well Casing a Public G Other Delta Type of Casing Li Irrigation Approx. ❑ Eastern Specifications [:]Cathodic Protection Depth Depth of Grout Seal 17 Geophysical Type of Grout tP�. D Other Surface Seal Installed by .}- Repair Work Done G Type of Pump H.P. State Work Done o. Well Destruction ❑ Well Diameter Sealing Material (top 50') _ {p Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION J (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 Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E[ Type/Mfg Capacity No. Compartments �I PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal I� SEWAGE SYSTEM fV1 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line i Q SEEPAGE PITS C] Depth Size Number SUMPS U 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) C 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 Is compersation laws of California." 0 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work fo'r which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The apcan t call far al require inspections. Complete drawing on reverse side. 111.1 �1'L!) Title: Date: 10••- ' Signed C F DEPART ENT USE ONLY Stk 465-6781 Application Accepted by Area Lodi 369-3621 �O Additional Comments: � Pit or Grout Inspection by Date Manteca 823-7104/y f Final Inspection by Date 4 r3 1 f1' 7 Tracy 835-6385 Applicant - Return all copies to: . Environmental 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, 41NF0 a C.4M Q._ f� 3-- 1 � �v 1 rpt 10/$2 500 ' EH 13-24 REV. 10/82 POUA 14-26