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I APPLICATION FOR.PERMIT I SAN JOAQUiN LOCAL,HEALTH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-67.81 w - DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in-Triplicate) ' Application is hereby made to the' San"Joaquir 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. 1862 for well/pump and the Rules anq Rasllionesof the San Jq in Local alth District. v Job Address ubdivisior Name Owner's Name J`PINAddress. r� Phone Contractor's Name LE FF �I �LT��t�lLicense No. �J � (7aa• Phone ,p TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ .. DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ OTHER` h DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES DISPOSAL FLO. PROP.� LUNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 01) .'F } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial , ❑ Open Bottom ❑Manteca Dia. of Well Excavation T Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well CasingT �� ❑ Public ❑ Other ❑ Del to --*�— ,�Type of Casing � LJ l f-1Irrigation Depth Specifications ❑ Eastern Specifications ❑Cathodic Protection 3 Depth of Grout Seal i y ❑Geophysical ,r I Type.of Grout . ❑ Otheri r } �, . 9 Surface Seal Installed by - i Repair Work Done ❑ Type of Pump = H.P. State Work Done P Well Destruction ❑ welli Diameter ' Sealing Material .(top 50') Depth i Filler Material (Below 50') j P , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑I , REPAIR/,.ADDITION bif(No septic tank or seepage pit permitted if public sewer is ., available within 200 feet.) Installation will'servo : Residence _ Commercial Other Number of living units Number of bedrooms Lot size ' Character of-soil-to adepth of 3 feet; t Water_tabie depth SEPTIC TANK +_. ❑ Type/Mfg* Capacity No. Compartments PYG. TREATMENT PLT, ❑ , 'Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM iDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING,LINE 'No._&_Lengt_h.,A lines4" Total length/size FILTER BED ❑ Distance to nearest: Foundation Property Line J SEEPAGE PITS (Depth *5 Size � - Number SUMPS ❑ Distance 'to-nearest: Well Foundation 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 k ordinances, state laws, a'nd rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature-certifies-the-folloWing-,."11certify that in the performance of the work for which this f permit "is issued, I shall not employ any person in such manner as to become subject to workmans.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 a ploy persons subject to workman's compensation laws of California." The pp t m t cal fllh all quire ns ect ns. Complete awing on everse_5 � .v� Signe Titl /1� 16f (/ _ Date: O ` R D EN U LY Application Acceptle y a Area _01 ❑ Stk 466-6781 I Additional Commenk ❑ Lodi 369-3621 Pit or Grout Inspection by Date �� ❑ Manteca 823-7104 t Final Inspection byj 7 .� Date - 6 , ❑ Tracy 835-6385 I Applicant - Return all copies to; . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE J�AMOUNT DUE AMOUNT REMITTED RECEIVED BY / DATaEq PERMIT NO. �7 `( INFO f I 1 t2 `S 0� 6 3�S S I. EH 13-24 REV. 10/82 hrj ( 10/82 500 14-26