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_ �- •. -y� m�� - Y ��3F f ..-+R+ _ - d`4J..-"`r�Vee� __—�T y.v .�y�S ✓'�� ... � 'N711", a�.'r 1K � +3 APPLICATION FOR PERMIT ISTRICT HATH DQJ ✓ W}`( SAN JOAQUiN LOCAL HEALTH Q AUG $1 TiM34 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �� Telephone (209) 466-6781 GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALT11W OEM= (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�a/nd R u til is the/��n oaq n Local Hea th District, � S /Q�� Job Address /� J d L./[yC.� 5 ubdivision Name � Owner's Name Address C9 Phone 4— Contractor's Name License No. Phone��4� lelo"Q� OB 1J. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT D DESTRUCTION l I PUMP INSTALLATION SYSTEM REPAIR 0 OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �—r �----,—:-INTENDED USE - . TYPE—OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ Industrial U Open Bottom Manteca Dia, of Well Excavation ��6omestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other [Ptelta Type of Casing 10 V<11— Irrigation Approx. ❑ Eastern Specifications G L ,/ D ❑ Cathodic Protection Depth Depth of Grout Seal b t 4' Geophysical Type of Grout UOther Surface Seal Installed by L7W �� /r Repair Work Done Fj Type of Pump W H.P. ' State Work Done m(1 ye. l•a Kl° W"�'F/ Well Destruction [J Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLAIION L1 REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) ^A Installation will serve: Residence _ Commercial _ Other W + Number of living units: Number of bedrooms Lot size -Water table depth If Character of soil to a depth of 3 feet: U ` ❑ Capacity No. Compartments SEPTIC TANK Type/Mfg PKC. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line,'_ - DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE,PITS,._. Depth size Number f _ SUMPS LJ Distance to nearest: AWell Foundation Property Line DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sta ws, an les and regulations of the San Joaquin Local Health District. -Z Home owner icensed agent' signature certifies the following: "I certify that in the performance of the work for which this permit is ssued, I shall not employ an erson i h manner as to become subject to workman compensation laws of California." Contract is hirin or sub- ractin c ifies following: "I certify that in the performance of the work for which this pe it is iss ed, I 1 emp su 'ect to orkman's co ation 1 sof California." The app icant r all ions. omplete dr i on re e• Signed X Title: Date: FO EPARTMENT USE ONLY Stk i 466-6781 } Application Accepted by Area � � Additional Comments: Manteca 823-7104 Pit or Grout Inspection 369-3621 Date Lod — Final inspection by . Date -Yi �.b'"�'/ ❑ Tracy 835-6385 Applicant - Return all copi iso: vironmental Health.Permit/services 1601 H elton Ave. P.O Box 20Q, 5 CA 9520 �1 FEE BASE AMOUNT` DUE AMO T REMITTED RECEIVED BY DATE PERMI NO. 10/500 EH 13-24 REV. 10/82 0 �J«9 �Cst 14-26 Com►,C n _j� 4NU �� g