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is APPLICATION FOR PERMIT SAA JOAQ6iN LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DAIS ISSUED DATE ISSUED (Complete in Triplicate)- Application is hereby made to the'San Joaquin Local Health District fora 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 03 and the Rules and Regulations of the San Joaquin Locale Health District. I Job Address_17,'9'Q� s�Ts�; subdivision Name. Owner's Name (`'-' I AddressPhone Contractor's Name License No. Phone qG 6_2! N TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION i , PUMP INSTALLATION L] SYSTEM REPAIR U'^. OTHER J a DISTANCE TO NEAREST: SEPTIC TANKSEWER SEWER LINES DISPOSAL FLO. � PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ! Industrial =-- -r kA [f Open^'Bottom=0-Mar`Ttec';� „�, Di.a..�of Wel 1w Excavation_- 4%M :- Domestic/Private - - L_.1 �Gravel Pack � Tracy �� Did. of Well Casing .� Public Other Delta Irrigation Type of Casing Lf g ; _ Approx.. Eastern s� Specifications Cathodic Protection ;;�Depth': e ,� 4 cations - . '% � } _. a� rn Geophysical ' Depth of Grout seal Other Type of Grout f_J - . ^ —..Surface..sea-1--I-nstall,edYby.— (b ' Repair Work Done Q Type"-of-Pump- — --�- H;P. State Work Done Well Destruction U lWell Diameter Sealing,Material {top 501} �. Depth Filler Material (Below 50'} lb f TYPE-.OF SEPTIC/WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage,pit permitted if public sewer is available within 200 feet.) Installation will serve: x Residence_- Commercial Other r Number of living units: Number of bedrooms Lot size A4�p Character of soil to a depth o'f,3,feet- 'L �- Water table depth SEPTIC TANK P-1 Type/Mfg i Capacity '.' p y No. Compartments PKG, TREATMENT PLT. EJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM �0 Distance to nearest: Well I Foundation ,� D P/ Property Line DESTRUCTION , LEACHING LINE a No. & Length of lines J, Q F _ Total-length/size FILTER BED Distance to nearest: Well OeArb f Foundation Property Line . SEEPAGE PITS f Depth Size. « Number J t4 SUMPS C1 Distance to nearest: Well Foundations _?C)l Property Line f DISPOSAL PONDS 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 rulesfagd 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 workmar� 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 ' thisermit is issued I shall employ p p y persons subject to workman's compensation laws of California." The applic t call for all. re uired spectiors. Complete draw on're erse;side. i Signed X Title: Date: ENT ry NLY /�/�tJ Application Accepted b ,~ Area y i Stk 466-678 Additional Comments: ; ' t` Lodi 369-3621 Pit or Grout Inspection bye Date ❑ Manteca 823-7104 Final Inspection by & ,02t Tracy 835-6385 Applicant - Return all copies to: vironmental Health.Permit/5ervi es�1601 E. Hazelton Ave., P.O,Box 2009, Stk., CA 95201 z i t s 'a'-- �4 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO LA 'i'_li 'L�^•u EH 13-24 REV. 10/$2 - IO/82 500 14-26