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,<. Ad h APPLICATION FOR PERM!T k j� SAN JOAQ41'. LOCAL d-ALTH D;ST (CT 1601 E. HA2€LTON AVE., STOCKTONCA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED ' PERMIT ExPIRES 1-YEAR FROM DATE I1. SUED -- -- (Complete in Triplicate) Application is hereby rude to the San Joaquin Local Health District fu.- permit to construct and/or install the work herein described_ This applicationjis 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 �]g g,• ,�fT�. kJ ubdivision Name Owner's Name 1 9+ [- �9AaUU�2= Address _ �I• r ... ... . . „ Phone Contractor's Name License No, _ Phone _ t TYPE OF WELL/PUMP WORK: u NEW WELT- WELL REPLACEMENT U DE5TRUCTION raj PUMP INSTALLATION n SYSTEM REPAIR OTHER U DISTANCE TO NEARES`: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FQUNDd'1ON _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRUBLEM AREA CONStRUCTION SPECIFICATIONS 1-1 Industrial^ ,T' Open Bottom []Manteca DiA. of Well Excavation - U Domestic/Private Gravel Pack [A Tracy Dia11. of Well Casing Public Other ❑Delta Type of Casing Irrigation Approx. Eastern � •� Depth Specifications Cathodic Protection Depth of Grout Seal LJ Geophysical Type of Grout LJ Other I Surface Seal Installed by Repair Uork Done Q Type of Pump N.P. State Work Done ,lh S7 Well Destruction EJ Well Diameter Sealing Material (top 51,} Depth it Filler Material (Below 50') , TYPE OF SEPTIC WORK:- NEW TNSTALLATION {J REPAIR/ADDITION (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: I Number of bedrooms ZT Lot size -'W k 3S I` r Character of soil to a depth of 3 feet: _/ gam ! w� Water table depth'_ SEPTIC TANK Li Tjpa/Mfg Capacity No. Compartments _ l PKC, TREATMENT PLT. [] T'y'pe/Mfg Lapaiity Method of Disposa._ - SEWAGE SYSTEM distance to nearest: dell Foundation Property Line DESTRUCTION ❑ � -- - �1 r LEACHING LINE j Na, X-length of lines — � _P• Total lergthysize.�e _ F + r FILTER BED �]- Distance to nearest: 1•lel l 7' Foundation �� Propertya•+E7 Line _ SEEPAGE PITS Depth -LCA!G-�f Size Number SUMPS L! Uistance to nearest: Well i Foundation Property Line r DISPOSAL PONDS w 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 this permit is issued, I shall not employ any person in such manner as to become subject to workmant coanpensation 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 emplo ersons subject to workman's compkeknsation laws Of California." The applica call f „ all re red spections. Comple a &dr ,' llon reverse side. Signed X _ Title: Date: I!' !�� zdo-&!—L�L— F DEPARTMENT USE ONLY Area _��1`(� Replication Accepted y ___ ` V / Stk 466-h1S1 Additional Comments:A — L�f ❑ Lodi 369-3621 Pit or Grout InspecCion by � Da �14Q'F 3. �] Manteca 823-7104 Final Inspection 4y� ' J Oath -ro-� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ServicesM 1601 E. Hazelton Ave., P_Q. Box 2009�$tk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED R-CEIVED BV l DATE PERMIT ND. INFO �� i� - --• � �� I-� �J�`tB 10/82 590 EH 13-24 REV. 18182 II 14-26 l I 1