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.r s 54 APPLICATION'FOR PERMIT -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO._ Telephone (209) 466-6781 DATE ISSUED, O o2� 6 Y � ..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 j described. This application is made in compliance with Sah Joaquin County Ordinance No. 549. for sewage or No. 1862 for well/pump ; and the Rules and R ulati ns of the San Jo quin Local Health.District. Job Address - Z, Subdivision Name Owner's Name � � ' 1yy/� S Address _� ` L� �� gyicv p _Phone Contractor's Name )_Ei=. w'&I��_ License No. Phone Ote, TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR OTHER ❑ i _ `�'- ` __ _ .r_ _ _... _ -. ' DiSTANCf T0"NEAREST 'SEPTIC`TANK SfWfR'CINES'-" DISP0�5AL FLD. 15ROP "LINE _ 7"" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS °" F1 Industrial u Open Bottom [ Manteca Dia. of Well Excavation r f Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing Public ' Other Delta ��.._ _ Type j F-1 Irrigation Approx. [] Eastern Specifications E3 Cathodic Protection Depth Depth of Grout Seal (�Geophysical Type of Grout Other Surface Seal Installed by Work Repair Work Done Type of Pum H.P. State Done P YP P Well Destruction U Well Diameter Sealing Material (top 50') ` 1 Depth Filler' Material (Below 501) ; (� TYPE OF SEPTIC WORK:' NEW INSTALLATION-U—REPA•IR/ADDITION (No septic tank or seepage pit permitted if public sewer is j available within 200 feet.) pp Installation will serve: Residence Commercia Other Number of living units: T� Number of bedrooms _ Lot size 3 Character of soil to adepth of 3 feet: r)% �__ Water table depth SEPTIC TANK Cji_. Type/Mfg -=Capaci-ty No. Compartments PKG. TREATMENT PLT. ❑. Type/Mfg Capacity Method of Disposal h j Distance to nearest: Well oundation Property Line ^~ LEACHING LINE �, f No..&..Length,of lines Total length/size I FILTER BEDf � Y Distance to nearest: Well Foundation Property Line - SEEPAGE.PITS Depth �_. ( Size 3 _ Dumber SUMPS ,Distance'to'nearest: Well Foundation Property Line DISPOSAL PONDS 6 �. I.hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances; state lawsr, 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." ; Contractors 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." ica t must cal for all r ired i pections. Complete drr ing o rse e. } S _ Title: f �']/�� ,f s� _ Date: F r03—. F DEPART�9 -T USE ONLY Application Accepted by �r�-r�,r<<rt., Area Vie. ,Stk 466-6781 Additional Comments Q,,ef-44-7,0 4Z /G zY [] Lodi 369-3621 Pit or Grout Inspction b - ,^,.Date �— Q Manteca..823-7104 Final Inspection by v Ad DatTracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. .Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f f EH 13-24 REV. 10/82 1O/B2 500 14-26