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c.'" APPLICATION FOR PERM;T SAN JCAQLIN LOCAL HFA.LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Applscation 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. Job Address aZp ajb Subdivision Name `0XI; Owner 's Name Address inffl±?t-e Phone ��5 W Contractor's Name fl� .tA1470_D License No, G Phoneme g7/ TYPE OF WELL/PUMP WORK: NEW WELL EJ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom M Manteca Dia. of Well Excavation Lj Domestic/Private Gravel Pack ❑ Tracy Dia. of-Well Casing 17 Public L Other ❑ Delta Type of Casing Lj Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') !v TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION EF (No septic tank or seepage pit permitted if public sewer is ` J available within 200 feet.) [ " Installation will serve: Residence _✓ Commercial _ Other Q Number of living units: I".' Number of bedrooms 13. Lot size IvAears t/L Character of soil to a depth of 3 feet: �i�- Water table depth SEPTIC TANK �j Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT, [J Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines -�� j Total length/size FILTER BED Distance to nearest: Well _Zgggg�__Foundation �I Property Line SEEPAGE PITS Depth '�/a Size ��r{ Number SUMPS U Distance to nearest: Well O�W Foundations Property Line ;L—,V DISPOSAL PONDS S 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 fallowing: "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_41 required ins ctions. Complete drawing on reverse side, Signed X Gi Title: f Date: Application Accepted y T U5 Area —3 �Stk 6-6781 Additional Comment - Lodi 369-3621 Pit or Grout Inspection by Date v—211 7W Manteca 823-7104 Final Inspection by Date /d� 2 -Y L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE �_BIIEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO LI EH 13-24 REV. 10/82 10/82 500 14-26 v