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'�- APPLICATION FOR PERI !T SRN JOAQLiN LOCAL HEALTH JiSIRICTn 16GI E. HAZELTON AVE., STOCKTON, CA PERMIT No. x Telephone (209) 466-b781 PATE 155llED(1_-D` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete ln.Triplicate) Application is hereby made to the San Joaquin Local' Health District for a permit to construct and/or install the work herein k described. This application is made in compliance with San Joaquin County Ordina ce No. 54 for sewage or No 18 2 for well/pump and the Rule and Regulations of the San Joaquin Local Health District, 3 Job Addre �. /C�A15 I A3 'Subdivision N T Owner's Name Address A hone 4 I (� S-S Phone`7 Contractor's Na 7f> t�/S 1�c✓mRll1C.0 License No. W TYPE OF WELL/PUMP WORK: NEw WELL ❑ WELL REPLACEMENT ❑ .DESTRUCTION ❑ + PUMP INSTALLATION SYSTEM REPAIR ❑' j4 'OTHER', U DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTllRE WELL OTHER WELL , PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTION SPECTFICAT1oNS l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation omestic/Private ' ❑Gravel .Pack' ''❑ Tracy - Dia. of Well Casing` R - .. _ `❑ Public ❑Other ❑ Delta Type of Casing Irrigation ' A rox. Eastern g PP ❑ specifications F-1Cathodic Protection t Depth Depth of Grout Seal i []Geophysical a.,7 Type of Grout ❑Other ! 3 Surface Seal Installed by S Repair Work Done ❑ Type of Pump f.C.�l - H.P. �` state Work Done Well,Destruction ❑ Well Diameter Sealing Material (top 50') — Depth � ., Filler Material (Below 501 TYPE OF SEPTIC WORK:'- NEW INSTALLATION ❑ ' REPA IR/ADDITION ❑ (No septic tank or seepage pit Permitted if public sewer is `Y available within 200 feet.) Installation will serve: Residence Commercial Other 01 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Capacity Method of Disposal._ PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE-SYSTEM : 0 ' Distance to nearest-: Well _ Foundation Property Line u DESTRUCTION LEACHING LINE ❑ No. & Length of lines Tota] length/size 3 FILTER BED ❑ r Distance to nea.rest:' Well Foundation Property-Llne , �__ F:. "•sem SEEPAGE-PITS Depth _ Size Number ❑ Distance to nearest: Well Foundation Property Line s SUMPS �I 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 of 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 (issued, I shall employperson subject to workman's compensation laws of Californj,a." The app]ic t must call for all. eq ired i pections. Complete dr ing on reverse side. y {{ f Title: Date: �I ( Signed X R D,EPARTM Q ( 5tk 466-6781 Application Accepted by rea (�"_' 3Lodi 369-3621 Additional Comments: Manteca 823-71 Ma 04 _- Pi'tror -ion-by Date e -�•^a._..:.. .. _ �•-- "Tracy Final Inspection by _- Date /! L Applicant - Return all copies to: Environmental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO J -- l-!01: 3 4 10/82 500. EH 13-24 REV. 10/82 14-26