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OF APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUE {Comp)ete-in Triplicate) L ``, / Application is hereby made to the San UDaquin Local Health District for a permit to construct and/or install the work herein described. This applicationis made in cUoaquincLocalhSan Health District and Ordinance Na. 549 far sewage or No. 1862 far well/ and the Rules and Regulatio 4I el ub iv, io Name ,104 Address f�Lf! �./j�l��-(� Phone Address Phone i4 Owner's Name tense No. A 1 Contractor's Name WELL REPLACEMENT DESTRUCTION TYPE OF WELL/PUMP WORK: NE4J WELL OTHER �"".�•(. LIN,_ k SYSTFM'REPAIR ❑ U i (/ PUMP INSTALLATION —` pRpp, LINE � DISPOSAL FLp. � SEWER LINES PITS/SUMPS pISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL A&Q&d.. OTHER WELL '��— FOUNDATION �. ° CONSTRUCTION SPECIFICATIONS �0 .TYPE OF WELL a '»PROBLEM AREAz INTENDED USE ��— Dia. of Well Excavation n Bottom t- [l Manteca cvt ---�- �- 4 I str,al P , -- �D "o Wel Casing F mesticlPrivate �Gravel,Pack_,- ublic Other '[]Delta Type of Casing EaSpecifications Lj irrigation (Z?DepEastern Depth Depth of Grout Seal ' Cathodic ,Protection / \ , Type of Grout: Geophysical _ ' °+ Surface Seal Installed by ° Other H P j State Work Done ' Repair Work Done FJ Type of Pump — Cal 50') F Well Destruction U .Well Diameter Sealing Material (top,Ar Filler Material (Below 50') Depth ti 1TION U (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: REPAIR/ADDITION NEW INSTALLATION LI availaait4in 200 feet.) Commercial � Other • f - lnstalYation will serve: Residence _ Lot size ,�—__ .Number of living units: Number of bedrooms Hater table depth Character of soil to a depth of 3 feet; Capacity �_��—�TNo. Compartments SEPTI'C'TANK ❑ Capacity Type/Mfg ✓ Method of Disposal „- P,KG"°'TREATMENT PLT. [J Type/Mfg Foundation Property Line SEWAGE SYSTEM Distance to nearest: Well Yf" `tDESTRUCTION _ Total length/size'. r No. k Length of lines " LEACHING LINE IJ Foundation Property Line FILTER BED, Distance to nearest: Well �. Size Number SEEPAGE PITS Depth -property_Li.ne.-_._-�--.rte w SUMPS - '�I Distance to nearest Wel-1 --Foundation- SUMPS DISPOSAL PONDS cordance � ork will be done in ac -1 hereby certify that I have rulepared this reguatPonsaofothenSanhJoaqat uin wLoc l Health District. performancewofhthenworkgfor which uin ythis i ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "I certify performance of the work for which permit is issued, 1 shall not employ any person in such manner as to become subject to workman!s compensation laws of California." i }Contractor's hiring or sub-contracting signature certifies the following:. I certify that in the p thi's permit is issued, i shall employ persons subject to workman's compensation laws of California. ' E The applicant st call for all r red inspections. Complete drawi on rev rse side. Date. - r Title: Signed X ° 0 DEPART ENT US ONLY St k 466-6781 Z3�� rea _•_�— Lodi 369-3621 / s Ap cation Accepted by ' Additional omments: pate _ Manteca 823-7104 Pit or ro Inspection Tracy 835-6385 Dat ' k F Final Inspection by P.O. Bax 2009, Stk., CA 95201 , onmental Health Permit/Services 160 E. azelton Applicant - .Return all copies to: PERMIT N0. k RECEIVED`BY .3 DATE FEE BASE AMOUNT DUE AMOUNT REMITTED INFO 7� k � 10182 500 `EH 13-24 REV. 10/82 i r 14-26