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APPLICATION FOR PERMIT SAN JOAQU11 LOCAL HEALTH DISTRICT G I, 1601 E. hA7ELTON AVE.; STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquir 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. Job Address1pg2ig al �' Subdivision Name Owner's Name e� S!/sY��!tf,^-4b� Address Phone Contractor's Name FGOyD tL��D _ License No. 2S7-7 Phone S' Y71 TYPE OF WELL/PUMP WORK: NEW WELL -71 DELL REPLACEMENT DESTRUCTION PUMP -INSTALLATION -{3 -- SYSTEM -REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOJNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE industrial U Domestic/Private Public Lj Irrigation Cathodic Protection Geophysical U Other TY?E OF WELL PROBLEM AREA [f Cpen Bottom [-] Manteca Gravel Pack Trdcy �jOther 0 Delta Approx. Q Eastern Depth 9 CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications Depth of Grout Seal Type of Grout bSurface Seal Installed by Repair Work Done G Type of Pump H.P. ^ State Work Done Well Destruction well Diameter Sealing -Material (top 50').— Depth Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION r (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _✓ Commercial _ Other Number of living unfits: -I. Number of bedrooms • Lot size Character of soil to a depth of 3 feet: �� f.�fi Water table depth SEPTIC TANKCapacity No. Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM a Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines % �1 Total length/size Property e 1 FILTER BED ❑ Distance to nearest: Well � Foundation P Y Line SEEPAGE PITS Depth Z -S Size Number i SUMPS Distance to nearest: Well -r• Foundation _�% Property Line DISPOSAL PONDS ED 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 ttiis 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant must call for all required Inspy ons. Complete draw' g on reverse side. r� Signed X Title:- ��?-rte Date: e, 9 — _ FOR DEPARTMENT USE�NLY Stk 466-6781 Application Accepted by Area_�� Additional Comments: ❑ Lodi - 369-3621 Pit or Grout Inspection b LDate C] Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental He th ermit/Services 1G01 L. laze ton, P.0. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFC s.�� e/4ig 9 10/82 500 EH 13-24 REV. 10/82 14-26 P