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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ID( 5/—O —01P 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 compliarce 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 Heal$h Dis r'c Job Address eO%WV !t ' 1 �� ubd�vis ontlName C3 i Owner's Name/,v k Yd CO ham, ni Serra' sey—� Phone Contractor's Name /! o v ry- e No. �Q 9A 3/ Phone 7�7Y.�S�/�' — i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION X PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION e AGRICULTURE WELL OTHER WELL PITS/SUMPS 9 INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S._ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public G Other Delta Type of Casing LjIrrigation Approx. ,� Eastern ❑ Cathodic Protection Depth AL Depth Depth of Grout Seal D Geophysical Type of Grout U Other Surface Seal Installed by / 4 Repair Work Done Type of Pump �.t.tit H.P. 3 Q State Work Done ioll P U eo �Y1 Qr o n Well Destruction Well Diameter � _ Sealing Material (top 50') e)91 7' . Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION J REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence 'Commercial _ Others% I � IT, Number of living units: Number of. bedrooms Lot size ^ { Character of soil to a depth of 3 feet: J Water table depth SEPTIC TANK Type/Mfg Capacity; No, Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Thi Method of Disposal C ; SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line (p DESTRUCTIONa1 y�■ 1k LEACHING'LINE'^.r " U` No`0Lehgth ofCl,ines ---= . .-.Total .length/size FILTER BED ❑ Distance to nearest: .Well Foundation Property Line �. SEEPAGE PITS Cj Depth Size Number F SUMPS Distance to nearest: Well Foundation. 4 *%t_ , Property Line DISPOSAL PONDS° El 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 employ any person in such manner as to become 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." {.M.. �w Pet The applicant ust call f r al required inspections. Complete draw in on reverse side. t Yr c't G Signed XTitle: A 4.. DEPARTMENT USE C LY - + a s�I Application Accepted by Area StI d-_'466-b981 + Additional Comments: ' Lo&;:�? 369-3621 :: t� I Pit or Grout Inspection by Date ' MarTtega 823-7.104; ; Final Inspection by Date i ❑ Tra y-t 835-6385 �. Applicant - Return all copies to: . Environmental ealth Permit/Services 1601 E. Hazelton Av , P.D. Box_2,0a9, Stk=, CA;r192-01 't A FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE -• PE,IRMTTti NO. INFO O/-L-�,$S W �" �' %7r o o. Gtu ! 0 EH 13-24 REV. 10/82 10/82 500 14-26 <Ca�✓e)-) i