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APPLICATION FOR PERMIT Q_ 7- SAN JOAQUiN LOCAL HEALTH DISTRICT 1601' E. HAZELTON AVE.,�STOCKTON, CA PERMIT NO. 71/ I I 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2 Z3'6 f/2Z D/Y e e Subdivision Name, Owner's Name LpR1 Af%4g�iy/ Address Phone i Contractor's Name ly License No. 3 V-7 Phone _466_ 140_7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION C4 ' 'PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ff INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V I� Industrial.- -open--Bot-torn --.---F-_1 Manteca- -Dia: of--We1IzExcavation ` # lJ Domestic/Private ❑ Gravel Pack E] Tracy Dia. of Well Casing Public Other Delta T-�Type of Casing irrigation A rox. Eastern g Depth Specifications Cathodic Protection Depth of Grout Seal f. I—]Geophysical Type of Grout U Other Surface Seal Installed by . Repair Work Done Type of Pump H.P. State Work Dane Well Destruction [ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is j c lips. available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: /0 - Number of bedrooms Lot size Z tj� C Character of soil to a depth'of 3 feet Water table depth 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 E DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well �. Foundation, Property Line i SEEPAGE PITS F; Depth J Size f Number 2-- SUMPS L1 Distance to nearest: Well Foundation Property Line 3 DISPOSAL PONDS D — 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. I 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, 1 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 certifier 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 t cal `for'al Uired• sec ions. Complete draw' on everse -de. V . I Signed X Title: F EPARTM tT USE ONLY 01 Application Accepted by Area — 5tk 46fi-6781 Additional Comments: Lodi 369-361 a Pit or Grout Inspection by Date Manteca 823-7104 Tracy 835-6385—} • Final, .inspection by � - Date. Ta/' 83 �.. . L_---.-. _. .. Applicant --Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rINF EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. O `7 a [ g 3 8 v-7141 10/82 500 ' EH 13-24 REV. 10/82 14-26 i