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APPLICATION FOR PERMIT SAN JOAQUiI,' LOCAL iHH4TH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (204) 466-6781 DATE ISSUED 1 dZ 7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ + (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 of the San Joaquin Local Health District. Job AddressAi }4"Zi� to,11W Sir.1_12k Subdivision Name Owner's Name ALLQ� Address �QS( y.J Cp_ yl�qWIp Phone Contractor's NameVFMplSN License No. �'��{. �+� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U 1 PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ �" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL r. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial r_1 Open Bottom ❑ Manteca Dia. of Well Excavation L'IDomestic/Private F-1 Gravel Pack El Tracy Dia, of Well Casing ' 1-1 Public , Other Delta Type of Casing r', irrigation Approx. Eastern Specifications Cathodic .Protection' Depth Depth of Grout Seal Geophysical Type of Grout Other , �- Surface Seal Installed by Repair Work Done F] Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION J REPAIR/ADDITION (No.septic tank or seepage pit permitted if public sewer is available within 200 feet.) �. Installation will serve: Residence L Commercial _ Other is P Number of living units: —I— Number of bedrooms Lot size y,?_d9, « Character of sail to a depth of 3 feet: d/ i y%ter table depth (� SEPTIC TANK Type/Mfg �IC :C-ji�rf ,>e��d[ Capacity I:2r)jP) No. Compartments 2 PKG. TREATMENT PLT.,[ Type/Mfg Capacity Method of Disposal s SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line II DESTRUCTION ❑ r 1 00 LEACHING LINE ' No. & Length of lines J �- �� Total length/sized © �® FILTER BED Distance to nearest: Wel loFoudation 3T `` ` Property Line 4 r SEEPAGE PITS ❑ Depth Size .F+. k- Number SUMPS Distance to nearest: Well Foundation Property Line y 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. i 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 workmank compensation laws of California." t Contractor's h' ingor sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit ssued, I shall employ person subject to workman's compensation laws of California." The appli u call fZ11 re ed dr "o'n-reverseesti ns, Complet side. +� Signed Ti-tle: Date: /nI s�. DEPARTMENT USE ONLY Application Accepted y Area �� [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Datie U., Manteca 823-7104 Final Inspection by yf/r/��^ r Date 835-6385 Applicant - Return a71 copies to: Environ a al Health Permit/Services-1601E. Hazel Ave„ P.O. Box 2009, Stk., CA 45201 www r nFEE BASE AMOUNT DUE AMOUNT REMITTEDFR�FCFIVED BY DATE PERMIT NO.INFO � ,o � �� •"�j " ! � � EH 13-24 REV. 10/82 10/82 500 14-26 4