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F L. A V �J -'en to f✓e- C � DO APPLICATION FOR PERMIT lite' 2 Q 1983 SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Za 3 SAN JOAQUIN LOCAL Telephore (209) 466-6181 DAZE ISSUED HEALTH DISTRICT PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) t r., 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 of the San Joaquin,Local Health District. Job Address &ArAW& Subdivision Name Owner's Name Address sa W1P__ Phone&M Jd2je—Itt 'f Contractor's Name Pury!Ence Dri erS Drelbn--^T=err License No. 3 ITU 3 , Phone 43 1— s41M TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial eU Open'Bottom "� 'Qanteca Dia. of Well Excavation " LJ Domestic/Private Gravel Pack' ❑ Tracy Dia, of Well Casing L7 Public F_IOther E] Delta T Irrigation Type of Casing 9 Approx. Eastern Specifications r Cathodic Protection Depth Depth of Grout Seal ' Geophysical i Type of Grout ❑Other Surface Seal`Instttalled by Repair Work Done Type of Pump H.P. ,.J49 State Work Done f Well DestructionE] Well-Diameter r_ Sealing Material_(topr5O') t Depth Filfler Materia 11 ,(Selow 50 ,)l L TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is : i available within 200 feet.) Installation will serve: Residence _ Commercial • ' Other Number of living units: Number of bedrooms ` Lot size Character-of soil to a depth of 3 feet: t. 4;r ` Water table depth SEPTIC TANK El Type/Mfg J �f Capacity 7 No. Compartments f PKG. TREATMENT PLT, Type/Mfg Capacity, Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 1 "'Foundation T Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total leng h/size ! FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number _.In, � SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED - ^ I hereby certify that .I have prepared this application and that the work will be done An,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 became subject to-workman� compensation laws of California." .i Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which li this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must c 1/floor all required inspections. Complete drawing on reverse'side. !� Signed X r/h,u1 /J!/ ire-r Title: ! Date: •� �—f ' }y 1 DEPA MENT USE ONLY Application Accepted by ; Area _ �. 5tk 466-6781 Additianal.�,Comments4• .t -• '-*' + Lodi 364-3621 j Pit or Grout Inspection by Date Manteca 823-7104 '# Final Inspection by C Date fO Tracy 835-6385 Applicant - Return all copies to:' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, .Stk., CA 95201 9 r EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.NFO 3 ! At 5 � EH 13-24 REV. 10/82 ` 10/82 500 14-26