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APPLICATION FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 L DATE ISSUED -lac �T1 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address G,4>-7e /Pcf• osrw1Pv Subdivision Name Owner's Name Noe- Perrey.`ee .- Address ;X gcts'x L. GHy)ev /;rG1 Phone Contractor's Name Z:,'Nj!/T/jG/r(/ d--; a_c, License No.f `/yy-ey/ Phone s TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTUANELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public F-10ther ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications F-1CathodicProtection Depth _ g 1 Depth_of Grout.Seal _. 4'" LJ' t ❑Geophysical � Ty pe of Grout r� ❑Other V � n �s Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. t State Work Done Well Destruction ❑ Well biometer Sealing Material (top 50') r Depth Filler Material (Below 50') :L TYPE OF SEPTIC WbRRK: NEW INSTALLATION REPAIR/ADDITION ❑ (Noseptictank or see4ge pit permitted if public sewer is - — - available within 200 feet.) serve:Installation will Residence Commercial Other /yo 6 4 114,y B Number of living units: .1. -- Number of bedrooms 3 Lot size AlAWA- Character of soil to a depth of 3 feet: C G.4 y 4,0,4M Water table depth SEPTIC TANK LCL. . Type/Mfg Avec G.0;Or Capac;ity,, J206 No. Compartments � � ..y PKC. TREATMENT PLT.y❑ a`Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM D"istance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE FJ No. & Length' of lines *t 8n Total length/size 146e ' FILTER BED ❑ Distance to nearest: Well 300 ' Foundation Ay ' Property Line SEEPAGE PITS yj Depth 23-x ---Size �3 " " — _Number— A: SUMPS ❑ Distance to nearest: Well 3 OO ' Foundation /a' Property-Line +3 s' DISPOSAL PONDS ❑ I hereby certify that [ 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 became 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 applicant mus call for all required inspections. Complete drawing on reverse side. " Signed X L Title: Date: PAR ENT USE ONLY Application Accep ed by Area _ ❑ Stk 465-67$1 Additional Comments: ' f '.N *l �k- ,, Lodi 369-3621 Pit or Grout Inspection by Date Q ❑ Manteca 823-7104 Final Inspection by �,� Date f !�� L7Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 01 E. Hazelton Ave, P.O. Bbx 2009, Stk., CA 95291 FEE BASE AMOUNT DUE- AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. f I' INFO EH 13-24 RFV. 10/82 10/82 500 14-26 j