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II APPLICATION FOR PERMIT SAN JOAQUIN LOCALLHEALTH DISTRICT } 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED � i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II�I� (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 applicationlis 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_ Subdivision Name Owner's Name 1+r1 Address - Phonep�� Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ., WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U 6 DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ^,-_ AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE_---- TYP,E4;DF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ' ' LJ ; p.�� Boiom Manteca Dia. of Well Excavation Domestic/Private D1 Gravelack � Tracy Dia. of Well sing i Public :° �s: Other Delta Type of Casing �jIrrigation �'Approx. E] Eastern Specifications t >- .T - ^rte Cathodic ,Protection t Depth - �. 1 Ceptlh of Grout Seal Geophysical I s ...... k _ ,Type of,Grout�,y. Other Surface Seal Installed by Repair Work bone Ej Type of Pump H.P. -wZState Work Done -, - Well Destruction ❑ Well Diiameter ? Sealing Material (top-50') "� w Depth II ; Filler Material (Below 50') �+ MTYPE OF SEPTIC WORK: NEW INSTALLATION,U REPAIR/,ADDITION (No septic tank or seepage pit permitted`if;public sewer is ! sow available within 200 feet.) Installation will serve: (Residence Commercial _,o@ther 1� I Number of living units: [Res7. idence of bedrooms ___ ___ Lot size-,=� 3. Character of soil to a depth of 3 feet �� Water table depth SEPTIC TANK EI Type/Mfg i� Capacity '�No-Compartments PKG. TREATMENT PLT. Type/Mfg r w Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well i Foundation Property Line DESTRUCTION $ } A LEACHING LINE No. & LengthoTotal length/size 'if lines r-F CJ FILTER -BED_ Distance;fa nearest: Well �� Foundat-i-on -°'a Property Line /f9 SEEPAGE PITS Depth Size R E Number SUMPS LI DWell Foundation r Property Line`�""-"�, ri DISPOSAL PONDS ❑ II ; II I I hereby certify that I have prepared ?this application and that the work will_rbe-done in_accordance with San Joaquin county ordinances, state laws, and rules and �Aulations of the San Joaquin Local, Health District Home owner or licensed agent's signaUe 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`, _compensation laws of California." Contractor's ring or sub-contracting signatur certifies the following; ;"I certify that iri't4ie-performance of the work for which this permi i issued, I sha 1 employ rson u ect to workman's compensation laws of California.' �. The appl call f all re e i cti ns. Com letp a�dr ' �rev�ersesid�e. , Signed Title: e^ EP MENT'USE ONL ' Application Accepted Area Stk 466-6781 € iY r . Lodi 369-3621 t Additional Comments: r IManteca 823-7104 Pit or Grout Inspection by .+" Date: 1� Tracy 835-6385 Final Inspection by Date, LI ; Applicant - Return all copies to . nvironmental Health*Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i _BASE-___-. _.AMOUNT_OUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i . ]NFO .- ..—�- _ _ .. ... .. ^.,�-.-n,-�.---. ..�.,..-,..^-,...-�•-�--^---�-^-.-�----, _ 1 / 2 500 _ EH 13-24 REV. 10/82 14-26 a� I