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2 'f Y /S M I rte�s I +°e- W o �. -"(oA)Ly a �e�s tb YOR010 APPLICATION FOR PERMIT SAN JOAQJii,- LOCAL HEALTH DISTRICT . F 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J (D Telephone (209) 466-6781 DATE ISSUED 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 Local HeaJ,th� D{si�irt�C� Job Address /9/00 G�o�[Y Crit Su division Nam Phone. o T' T5 �i f . Owner's Name' U6 17`� %k 0. P_ - Contractor's Name 819 rYJ2r• License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ _ A PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 17f 1, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O I f Industrial U Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑Other Delta Type of Casing Irrigation Approx. L] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') I� aDepth Filler Material (Below 501 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is G SEPTIC WORK: NEW INSTALLATION I in 200 feet. TYPE OF S � b e within ) vailable Installation will serve: Residence Commercial i Other t Number of living units: �._ Number of bedrooms Lot size r1 C e L Character of soil to a depth.of 3 feet: Ra c k - C La w d. l P. Water table depth 7 r T e/Mf rl g Capacity /r�i (r� No. Compartments �Q/J a IZd SEPTIC TANK Type/Mfg 9 5 i PKC. TREATMENT PLT. [ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well- 3s� Foundation �� ' -- Property Line. DESTRUCTION b LEACHING LINE , Foundation .? Property No. & Length of lines _ 3_ Total length/size e l Proper .Lir+e- 1 Jr�o —�- FILTER BED ❑ Distance to nearest: W SEEPAGE PITS Depth ';' Size Number SUMPS ❑� Distance to nearest:, Well ' Foundation Property Line ❑ } 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 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 6f 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." The applicant must call fo all r uir�d inspections. Complete drawing on reverse side. Date. 2 �� Signed X ��,�fJ'•"r,'„�" Title: R RTMENT SE ONLY Stk 456-6781 Applicatio Accepted by Area ❑ Lodi 369-3621 Additional Comments: Date Manteca 823-7164 ❑ Pit or Grout Inspection by , Tracy 835-6385 Final Inspection by Date � Applicant - Return all copies to: Environ ental Health Permit/Services 1601 E. Hazelton Ave.,' P.U. Box 2009, Stk., CA 95201 PERMIT NO. FEE SASE AMOUNT -DUE AMOUNT REMITTED c_,yR�E�CEIVED 8Y DATE -p� f / T INFO ✓ f ' $� " ! b(Q 11 10/82 500 EH 13-24 REV. 10/82 , (Vj �� 14-26