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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 16CI E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 13—7A ` Telephone (209) 466-6781 DATE ISSUED 211.6 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 n Re ulations of the San Joaquin Local Health District. Job Address es � �li�Qh� D ;r1 Subdivision Name 17 Owner's Name i ArV-q_ Address r.0, LTf Phone -,5 ��XTO Contractor's Name License No. 12 Phone TYPE OF WELL/PUMP WORK: - NEW WELL ❑ WELL REPLACEMENT �] JDESTRUCTION U " —PUMP'INSTALCATIONw(�- —SYSTEM-REPA-IR—L_f'—-OTHER-"-[7J- DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOS'AL FLD. PROP. LINE L. FOUNDATION-' µ+ 't",�14 AGRiR•ICULTURE'WELL OTHEf_I ELL PITS/SUMP_S'_ W INTENDED USEs a TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, r Fj Industrial U Open Bottom Q Manteca Dia.of WeTI"Excavation,� Domestic/Private �.] LJ; ; i [� Gravel Pack Tracy Dia. of Well Casing , ,Pub'l,c; F� Giflther 0 Delta ' Irri ation Y'Type-of Casing# V ITi 9 Approx. �Eastern 7 Specifications 60 . ❑Cathool'ic Protection {� epth"', + ! w Depth of Grout-•Sea4�-,T--^-, Geophysical 1.i� -� Other +. Type of Grout I � F 4 z ... �_ Surface Seal installed by vA �' --_ LJ . ReQ it Work Done;Q CIype}}of�Pump ,.L i� H.P. State Work Done _ *` + � N Well Destruction F-1 Wel I' Diameter .,Sealing Material (topi50')ts /• J=-I 4: ' Depth Filler Material (Below f, 197 T TYPE OF SEPTIC WORK: NEW INSTALLATIONN REPA k/AkDDITION `P5,7116 s6-ptie tank'or-seepa,ge!pit-permitted i.f,_-publicrsewer_i.s� a Iable within 200 feet.},+,,`� Installation willsee Residence — Commercial Others � �- -^f J__Z ' Number of living unit: , �, Number of bedrooms �� tlfot size e p Y . ,F�-- Gha•ratter-of�soi7�to-a�deptFh of`3�feet "" Water table depth SEPTI C TANK Type/Mfg ` .; Capacity 1�� No. Compart�s � PICG!'fREATMENT PLT. [! Type/Mfg Capacityr Meted a disposal SEWAGE'SYSTEM Distance to nearest: Well Found tion : ope ty Line' !' pESTRUCT.10 ! LEACHAG. LINE No. & Length of lines go Total length/size FILTER BED Distance to nearest: Well oundation r I Property Line F SEEPAGE PITS Cj Depth -, f Size Number '+ ~ jj i SUMPS �� Distance to nearest: We11 Q r Foundation Property Line DISPOSAL PONDS ❑ '� J f ' =- 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, s f 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 is is ed;. I`shall employ persons subject to workmart£s compensation laws of California r LL The applicant for 1re uired inspections. Complete( 'd,ra 'n� on everse s'de- t Signed X Title: t - ?� 3 - _�D4 :rrF DEPARTMENT USE ONLY tApplication Accepted by //�}ya..� Area =67,81 Ad"dit'ional-Comments: Q—Lodi"`"�`369 3621 Pit or Grout Inspection liy ' 4�tivh C/rr� r �,/ agate /, L7-Manteca 823-7104 Final Inspection by DattVt'5'7%% V r a c y 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. !Hazelton-•Ave%J.P�-0. Box 2009, Stk., CA 95201 isr,li FFE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �PERMITN0. • INFO EH 13-24 REV. 10/82 10182 500 14-26