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APPLICATION FOR PERMIT t SkN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. I Telephone (209) 466-6761 DATEISSUED C!-13j—g3 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 al Health District. , Sob Address iover- 4 Subd��iv.i/�s�jion,Name., _ }I Address -J"L. a� nG hon t Owner's Name ung Phow_w_ Contractor's Name License No. y TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION a a OTHER O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OU PROP. LINE f SEWER,LINES 4 DISPOSAL FLD. it DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } CONSTRUCTION SPECIFICATIONS € INTENDED USE TYPE OF WELL PROBLEM AREA ` ' Dia. of Well Excavation Industrial ❑ Open Bottom �]Manteca ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public ❑ Other ❑Delta Type of Casing• rax. Eastern Specifications Ljlrrigation APP Etn❑ Sp ,. Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ( ❑Other Surface Seal Installed by ik epair Work Done FJ Type of Pump H.P.H State Work Done i Well Destruction ❑ Well Diameter Sealing Material (tap 50') Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTAILRTION �� REPAIR/ADDITION ❑ (No septic tank or seepage piavailableewithinif u200cfeet.) is n Installation will serve: R/idence Commercial _F Other Number of living units: Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PIG, TREATMENT PIT. [] .Type/Mfg Capacity SEWAGE SYSTEM Distance to nearest: WellFoundation Property Line DFSTRUCTION Q No. & Length of lines Total length/size LEACHING LINE I� 9 Pro erty Line FILTER BED ❑ Distance to nearest: Well Foundation A SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line -. L—I - DISPOSAL PONDS ❑ r J I hereby certify that I have prepared this application and that.the work will he done in accordance with San Joaquin county a ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature cersoriin suchs the fmannernas to become subject that ntohworrkman� compensate performance of ionwlaws,of California." permit is issued, I shall not employ any p Contractor's h, Ing or sub-c tracting signature certifies the following: "I certify that in the performance of the work for which this permi is i sued, I sh 1 em loy persons subject to workman's compensation, ws of California." G The app can ust ca] al quired inspections. Complete dr win on revers side. ,r1 �/� Title: Date: ' Signe X _ FOR DEPA MENT USE ONLY Area d Stk 466-6781 I Application Accepted by E] Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection by Date LJ Date � ❑ Tracy 8 5-63$5 Final Inspection by p Box 2 Stk., CA 95201 Applicant - Return all pi to: Environm a H It P r /SOY Vic 1 H el on DATE PERMIT N0. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO vd �ar0 NQ i_t3-g3 77—kC5 1 U 10/82 500 EH 13-24 REV. 10/82 C, Lc- 14-26