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�} !� APPLICATION FOR PERMIT 7 1 SAN JCAQUiN LOCAL HEALTH DISTRICT ! 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED � 1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - F I'Y (Complete in Triplicate) i 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 it compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Re uI tions of the San Joaquin Local Health District. /Q � r��f�s RIO Subdivision Name Job Address Owner's Name Ll1 LL./ �� Address /p�Q/_ �0/Ji4�2U/bL/S Ate_ Phone ��'�//� Contractor's Name 'A:!!", W&g2.Z�._ License No. Phone t_a,071 I�. TYPE OF WELL/PUMP WORK: ! NEW WELL WELL REPLACEMENT -DESTRUCTION U E�UMP`INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE } 1?' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �J a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �17 Industrial U Open Bottom [] Manteca Dia. of Well Excavation L.J Domestic/Private ,F-1 Gravel Pack [] Tracy Dia. of Well Casing ! 0 Public F-10ther ❑ Delta Type of Casing V Irrigation Approx. Eastern � Specifications" Cathodic Protection Depth f Depth of Grout Seal ! Geophysical r } � Type of Grout ' LJ Other Surface Seal Installed by Repair Work Done Type of. Pump ' H.P. z State Work Done �. Well Destruction U Well:lDiameter Sealing Material (top650') CJ- "Z1 ` ' Depth', Filler Material (Below 50+) 10 E --- TYPE OF SEPTIC WORK; NEWLp< CJ_ (No REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is 1� 1 available within 200 feet.) - Installation will serve`:` Residence / Commercial _ Other Number of living units:q Number of bedrooms Lot size 1x74.71 Character of soil to aa!!!!lldepth of 3 feet: 4,_1 � Water table depth SEPTIC TANK Type/Mfg &,a %�fL_ 'Capacity /mid_— No. Compartments .2- PKG. TREATMENT PLT. ' Type/Mfg 1- 'Capacity Method of Disposal SEWAGE SYSTEM iDistance to nearest':i Well 7�, Foundation /p Property Line /d DESTRUCTION LEACHING LINE No. & Length of lines Total length/size w/Ze FILTER BED p-Distance to nearest: Well 7s, Foundation S- Property tine /p L+ SEEPAGE PITS Depth Size z� Number j SUMPS Distance to nearest: Well /M Foundation s Property Line 1 2-0f DISPOSAL PONDS s ❑ / ,:r�� C�� r �r+, I hereby certify that I'6aJe prepared„this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a'hd rules and regul'ations.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 ! j 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." The applicant must call for all requi ed inspections. Complete drawing on reverse side. Signed X t' eOF z4x, Title: &Yr-- Date: �,,nn• nF A��lP�R`EENT USE ONLY 5tk 466-67$1 Application Accepted by tx+ 11�'�� Area v� Lodi 369-3621 Additional Comments: �! Date }•�1- Manteca 823-7104 Pit or Grout Inspection by L� Final Inspection by Date L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 !M FEE BASE ��AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. 0 � k EH 13-24 REV. 10/82 ! 10/82 500 14-26