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APPLICATION FOR PERU jE SAN JOAQU2, LOCAL HEALTH Di,STRICT 1601 E. HAZELTON AVE, STOCKTON, CA PERMIT NO. Telephone (209) 4606781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED p �3 (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 ofythe San Joaquin Local Health District. , Job Address M2-168 PAc SuIbdiv�_iision Name .d�A1Sr-Ee91G G!! - EC�?R Owner's Name �/1R/1/� f, S-rAAIM Aj Address �'•25 � Phone Contractor's Name .FL-0)o,j �44 0&j4 , License.No. 411, ')�,74, Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 .i �---'- -PUMP- I•NSTAL-L-AT10N.- ❑•—SYSTEM-REPAIR Y-- _D--.� �-OTHE-R—L_- Y iDDISTANCE TO NEAREST: SEPTIC TANKII SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION I�� AGRICULTURE WELL OTHER WELL PITS/SUMPS ^� F- W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { Industrial ❑ Open Bottom ❑ MantecaVl Dia. of Well Excavation i lJ Domestic/Private ❑ GralvelPack ❑Tracy Dia. of Well Casing I] P01 is ❑Other ❑ Delta �..+ Type of Casing t Lilrrigation �� Approx. ❑ Eastern p Specifications Cathodic Protection Depth 1 ❑ �; Depth of Grout Seal ❑ Geophysical Type of Grout 9 f❑Other # Surface Seal Installed by � Repair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑f Well Diameter Sealing Material (top 50') r Depth Filler Material_(.Be1ow_50_)r �_ ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Z (No septic tank or seepage pit permitted if public sewer is t I available within 200 feet.) Installation will serve: Resi�ence _Commercial _ Other Number of living units: Number of bedrooms '?�_ Lot size n Character of soil to a dpth of 3. feet: ��]j _ Water table depth SEPTIC TANK PType/Mfg j rIA-16= Capacity No. Compartments e PKG. TREATMENT PLT. ❑ Type/Mfg �+. ,- Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest:' Well Foundation Property Line - , _DESTRUCTION ❑ .0. LEACHING LINE No. & Length of lines -}/ ]® Total length/size f IX Z j FILTER BED ❑ DistanCe to nearest: Wel-I, Foundation Property Line Ep SEEPAGE PITS ❑ Depth Size Number SUMPS ❑I Distance to nearest:, Well F6undation �• ✓~* Property4L,ine € DISPOSAL PONDS ❑ �1`` ~�#'{ ^ a I hereby certify that I have prepared this application and that the work will be'dgne in accordance with San Joaquin county F ordinances, state laws, and rules and regulations of the San Joaquin Local HealtK40istrict. 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 wortZ`tnan5 compensation laws of California." 3 Contractor's hiring or suh-contracting signature certifies the fol Iowing:�"fi-certify'athat in-the-performance of the work for which I this permit is issued, I shalrl14ploys , person .subiect to wdrkman'"sicompensation j Awsrof California." The applicant must c 11'fo all required 'rispe�tionns.L mplete drawing on reverse side. Signed X Title: ' t Date: d'7• �� i �—p-ica—.-A-i Ik. FO DEPARTMENT SE ONLY .� 6781 Application Accepted 6y? C� Area12� 01 ❑ Stk'"� ''466-6781 x � - Additional Comments: 1�1".� fi _ lLodi 369-3621 r Pit or Grout Inspection bye f. _ " :� Date t + ' Manteca 823-7104 s Tracy.-.835-6385, Final�`Iiispection'by Date T� � :�' • -�'�^ - ❑' •-"�-� Applicant - Return all copies do Environmental'-Hes h Permit/Services 1601 E. H Alton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNTfREMITTED '?RECEIVED BY. , . �%',eDDATE �t' PERMIT NO. INFO �p 3 0 EH 13-24 REV. 10/82 I� 10/82 500 14-26 I