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APPLICATION FOR PERMIT , ; �7 SAN JOAQUIN LOCAL }i_ALTH :DISTRICT a ;d/ 1601 E. HAZELT014 AVE., STOCKTON, CA PERMIT NO. Telephone,(209) 466-6.7811. DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 04TE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. Gt rye Job Address subdivision Name y I!�F_/ kT9 S.EP1!Address Phone Owner's Name 1YJEA1�Ial yy��• Contractor's Name pp,P�1?/9JV�� 1 Liz s-Co• Phone 4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION S yVE/. 14 B-"p AA010 N/hOZ'"7. ,_.,._PU`M`P_INSTALLATION_F�_ _SY.STEM.,REPAIR_ L-, n OTHER, DISTANCE TO NEAREST; SEPTICITANK SEWER LINES _DISPOSAL FLO. PROP. LINE FOUNOA. ION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE I� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F {M] Industrial U Open Bottom Manteca d Dia. of Well Excavation }J Domestic/Private (� Gravel Pack Tracy Dia."of Well Casing ° Public rl Other Delta Type'of Casing r Irrigation 'IN Approx. [] Eastern ; ..Specifications I ❑ Cathodic Protection Depth � Depth of Grout Seal Geophysical Type of Grout - U Other Surface Seal Installed by /�dd�'/�1A�►/.� j+I�iJi� 5Ji Repair Work Done ❑ Type of Pump H.P. State Work Done 54ee l Well Destruction Well Diameter 2 11 Sealing Material (top 50') If Depthi� Filler Material (Below 50') UV TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence _ Commercial _ Other U1 Number of living units: Number of bedrooms Lot size N + Water table depth Character of soil to a depth of 3 feet: -- -- - s SEPTIC TANK ❑ Type/Mfg �Capacity , No. Compartments ; PKG, TREATMENT PLT. Type/Mfg Capacity . Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION IM LEACHING LINE jJ No. & Length of lines f Total length/size FILTER BED Distance to nearest: Well i Foundation Property Line p SEEPAGE PITS ❑ Depth Size i Number GSUMPS �� Distance to nearest: Well Foundation .r7- •r Property Line DISPOSAL PONDS.. ❑ . 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 empley any person in such manner as to become subjectato'workman� compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant 1 or al fired inspections. Complete dr ging n reverse side. t f Signed X h Title:{ Date: I� PARTMENT USE ON 4 [ Application Accepted by Ar a Q 5tk 466-5781 Additional Comments: Lodi 311 69-3621 Pit or Grout Inspec Date Manteca 823-7104 tion Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copi Envir.nmertal Health Permit/Services 160k E.. Hazelton Afire., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED,BY DATE PERMIT NO. IF INFO �'� ��-- FH 13-24 REV. /B2 p � 1 �j 10/82 590 1 I 14=26 y �..-�-.--:..r _ :�L e:K 1 � _ -° iM � &��) --