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APPLICATION.FCR PERMIT SA.N JOAQUIN LOCA'_ HEALTH DISTRICT 1601 E. HAIELTON AVE., STOCKTON, CA PERMIT NO. _ S Telephone (209) 466-6781 DATE ISSUED 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1.862 for well/pump and the Rules and Regulations of�f the San Joac.u'n Local Health District. Job Address 2-L-, a¢ . -J. [! irve '04 Subdivision Name '),IV -C� Owner's Name0a.,4hyY// A - Address Phone - Contractor's Name G c?k-- 0"-, t-rr y 4a License'Na, :/? 2 Z Phone S"�1 M TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U W PUMP INSTALLATIONrV SYSTEM REPAIR U OTHER U y l W DISTANCE TO NEAREST: SEPTIC TANK [ S SEWER LINES DISPOSAL FLD. Q PROP, LINE 1 2 l/n" FOUNDATION f 57tj r AGRICULTURE WELL OTHER WELL [�� # PITS/SUMPS /C/n� V1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. 1-1 Industrial U Open Bottom Manteca Dia. of Well Excavation I Domestic/PrivateGravel Pack- Q Tracy Dia. of Well Casing r! Public jOther Delta Type of Casing A V c- Irrigation Approx. E] Eastern Specifications �1 S lbo Cathodic Protection Depth � Depth of Grout Seal -0 i L7 Geophysical Type of Grout Other ! �--) Surface Seal Installed by [�cyr�cr-- ,f7Yr Repair Work Done Lj Type of Pump S V b H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materiall(top.50') l Depth Filler Material (Below 50')' TYPE OF SEPTIC WORK: NEW'INSTALLATION L-1 -.REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is .� available within 200 feet.) : Installation will serveResidence 'Commercial Other Number of living units: Number of bedrooms *r Lot size "'"" Character of soil to a depth of 3 feet: ""� bla.tert,table depth a;r SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity ""+ -Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation 1'Proper.ty�Line DESTRUCTION LEACHING LINE LJ No. & Length of lines Total length/s'ize # FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number a r SUMPS Distance to nearest: Well 1 Foundation ...011' Property Line DISPOSAL PONDS ❑ � 4 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 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 applicartAnust call for/all reqVired inspections. Complete draw'ng o reverse side. �{ Signed XC'�t LdZF - Title: G}�. Date: F R It Application Accepted by DEPARTMENT USE ONLYArea l� ❑ Stk 466-6761 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date A Manteca 823-7104 Firal Inspection by Date Tracy 835-6385 Applicant - Return all copies to; Enviro n al Health Permit/Services 1601 F. Hazelton Ave., P.D. Box 2009, St k., CA 95201 FEETASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE EPERMIT NO. INFO EH 13-24 REV. 10/82 �---�_ 10/82 500 14-26