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APPLICATION .FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT M 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ` ; Telephone (209) 466-6781 DATE ISSUED i PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED I (Complete.in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he i described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump y and the Rules and Regulations of the San Joaquin Local Health District. F Job Addresss�f` /�,�y .� Subdivision Name Owner's NameY , 1l�A' Address Phone (387�i, 4� Contractor's Name RRA S License No. Phone lf—Wv z TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT ❑ DESTRUCTION } PUMP INSTALLATION SYSTEM REPAIR OTHER L3 LN DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1; F 11DISPOSAL FLO. PROP. LINE ((} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (1 y 1 INTENDED USE TY?E30F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , J Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy -i'N t Dia:of Well Casing 17fublic �J Other ❑ Delta Type of Casing f L_ilrrigation fApprox. [J Eastern Specifications k 1 Cathodic Protection Depth 1 T * ; Depth of Grout Seal Geophysical Type of Grout 1 T Other w, r U r Surface Seal.Installed by q Repair Work Done Type of Pump# H.P. State Work Done p } II Well Destruction U Well Diameter. Sealing Material (top 50') _ /sN,, i s Depth ` Filler Material {Below 50') V` I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION YJ (No septic tank or seepage pit permitted if public sewer is r3, available within 200 feet.) Installation will serve: Residence Commercial X Other Number of living units: Number of bedrooms Lot size. BO lc `a 1 F Character of soil to a depth of 3 feet: Water table depth ap fir`• I � SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, Type/Mfg Capacity i Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line , I DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size"""" ` FILTER BED Distance to nearest: Well— foundation kProperty Line [� SEEPAGE PITS KA MPDepth Z,f' Size y ,�3 Number Z- ' SUs rLYj Distance to nearest': Well _ Foundation aro Property Line 1.7 # 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. N I i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for.which this F 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 subcontracting signature certifies the following: "I certifyathat in the performance of the work for which this permit is issued' shall shall employ persons subject to workman's compensation laws;of California." +. The applicant must cal'1 for a requi i pections. Complete drawin or reverse idt. { Signed X Title: y4 1 Date: 6� �- OR DEPARTXENT USE,PRLY J f Application .Accepted by ''�T 4li 4 Area _ _# ❑ St_k 466-6781 ; 1 Additional Comments:N., ❑ Lodi 369=3621 Pit or.Grout Inspection+,by +. t. t Date Manteca 823-7104 ; Final Inspection by ' l w Date �i Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. j INFO O 5�5�8 t k EH 13-24 REV. 10/82 - 10/82 500 € 14-26 f