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APPLICATION FOR PERMIT 1 '*- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. x Telephone (209) 4b6-6781 DATE ISSUED �� (} F= PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , / fA I/ LC�lete�iry�,TTri i "to� A Application is hereby madee to the San Joaquin Local Health- 'ict 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 6 cion Name d _M uZA Owner's Name'_ -� L Address _ art Phone Co-ntractor's Name License No. -/ 6_ one 6,y Ph o TYPE OF WELL/PUMP WORK NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial "E-1 Open'Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private L_I - _ �Gravel Pack � Tracy Dia. of Well Casing _ �1 ❑ Public ❑ OtherEl Delta Irrigation - Type of Casing Lj 9 Approx. Eastern ❑ Cathodic Protection Depth Specifications ! Depth of Grout Seal Geophysical +, ❑Other Type of Grout Surface Seal Installed by Repair Work Done FJ Type of Pump H.P. State Work Dane -Well Destruction ❑ Well Diameter_ Sealing Material (top 501) r - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence uV Commercial Other Number .of l iv ng units: _� >Number of bedrooms _ Lot size _ I,.F A_ k Characteaof soil to a depth. of 3 feet Water table depth _ ; _ j'� SEPTIC TANKType/Mfg Capacity No. Compartments- PKG. ' Type/Mfg;Y � _ y � ''�' -. TREATMENTPLT. � �- 'Capacity .�.l�r3 _ Method of Disposal SEWAGE SYSTEMDistance to nearest: Well TO --Foundation j Property Line ` Y `DESTRUCTION ❑ S i LEACHING"-LINE - ❑ No. & Length of lines Zy -Total length size FILTER BED Distance to nearest: , Well L'?� Foundation � -� Property Line 4 SEEPAGE PITS _❑ Depth Size - Number SUMPS Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS I hereby certify that I have prepared thisapplication and that the work will be done in accordance with San Joaquin county ordinances,• state laws, and rules and regu-lations of the San Joaquin Local Health District. M Home owner or licensed agent's signator certifies the following: "Y certify that in the performance of the work for which this permit is issued, I shall not employ a person in such manner as to become subject to workman§ compensation laws of California." Contractor's hiring or sub-contractin ignature certifies the following: "I certify that in the performance of the work for which this permit is issued I shall em lo er ons ub' ct to workman's compensation laws of California." The a"ppl ' ,1 '�s c r Complete drawing on reverse side. /�� Signed r�r/ � Title: �(/J1l Date: t DEPARTMEW USE LYQ' � Application Acce ed by v r a SLk 466-6781.- I Additional Comments.: ❑�fLodi 369-3621 Pitlor Grout Inspection Date Manteca 823-7104 Final Inspection by 4 Date Tracy 835-6385 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, 5tk., CA 95201 FEE BASE- AMOUNT -DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO ' s EH 13-24 REV. 10/82 — 10/82 500 14-26 \��.