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APPLICATION FOR PERV4iT , SAN JOAQUiN LOCAL HE�.LTH DISTRICi 1501 E.. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 GATE ISSUED PERMIT EXPIRES 1 YEAR FRCM DATE ISSUED (Complete in Triplicate) t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein i described. This application is made in compliance with San Joaquin County Ordinance No:. 549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. - Job Address 1 Subdivision Name // Owner's Name ri A I-LECOddress5- na � Phone �o 2 Contractor's Name License=No. O i Z Phone TYPE OF WELL/PUMP WORK: NEWTWELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR j 1 OTHER �j pC7 DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES DISPOSAL PLD. PROP. LINE I PITS SUMPS RGRICUL TURE WELL OTHER WELL PITS/ SUMPS g® �ZQ_.�.— j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial MWn-fe-ca"'� UiS of—We'1'T-Excavat bn""j .�d�'7eJ €"�2,1 fill Oomestic/Private 0 Gravel Pack F Tracy Dia. of Well Casing i� y 0 Public LJ Other [] Delta Type of CasingooS►_„�� Lj Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal_ ! I� ❑Geophysical Type of Grout U Other S,?face Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State W rk`Dore j Well Destruction U Well Diameter Sealing Material (top . .— Depth FiTI'er Material ow 54') TYPE OF SEPTIC WORK NEW INSTALLATION L1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 7' available within 200 feet.) Installation willserve: Residence — Commercial Other E j Number of living units: Number of bedrooms Lot size Character of soi Ato a depth of 3 feet: Water table depth . SEPTIC TANK Th Type/Mfg erpaity No. Compartments PKG, TREATMENT PLT:�F] Type/Mfg Capacity Method of Disposal ; SEWAGE SYSTEM R Distance to nearest: Well f Foundation Property Line DESTRUCTION - 1 LEACHING LYNE , LJ No. & Length of li if .04110* Tgtal•.l ength/size,, a FILTER BED:_ : � Distance to n est: Well +#FauPdator �-'" IPropiry Line s SEEPAGE PITS Depth Size ,, ,,,, 1 -AlNumber _ ) Dista e to nearest: Well to foundation Property Line ; M DISPOSAL PONDS j❑ �3 ---".� # t1 hereby certify that I have prepared this application andbatjthe work will be done.,4in accordance with San Joaquin county -ordinances, state laws, and rules+and regulations of the San Joaquin Local Iealtli.D.5trtict. Home owner or licensed agent's signature certifie§ the following: "I certify that in fh`e�Iperformah e of the work !for which this .permit is issued, ljshal9 not employ any person inisudh manner"as to-become subject`to vlorkman�compensation laws of California." f,,.'^-.gid-+..^+,Frt, Contractor's hiring or.sub-contraAinq signaturejcertifies the 'following: I'cer't�fy khat in the performance of t o work for which :this permit is.issued, I shall employ persons sut- i to.workiran s compensation laws of California." The applicant st call_for 11 'ref d inspections Complee drawing �Onrvers� side. t ii t'l F e— Signed X, �-M. Title: 0�✓ ��< Date: /5 a D TME SE ONLY „ / r Application lccepted by r"'iArea :Stk 6-6781 i s Lodi Additional;Comments: - G2 5 44Hate 71b , . Pit or Groutllnspection by 2 Manteca 823-7104 (77J Final Inspection by Date� � ❑ Tracy 835-638=5 Applicant - Return all copies to: Environmental Health P rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k.; CA 95201 t -- FEET'—v- BE-'�- ;AMOUDUE AMOUNT REMITTED - RECEIVED BY DATE _ PERMIT N0.'NF �NT,� 10/82 504 EH 13-24 REV. 10/82 14-26 r