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�T fJ t�l APPLICATION FOR PERMIT L) SAN JOAQUiN LQCAL HERLTH DISTRICT p f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466'-6781 DATE ISSUED �{ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r ZZZ (Complete in Triplicate) Cand ation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ibed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump he Rules and Regulations of the San Joaquin Local Health District. Job Address �. g6. A�&R 6 W1 LZ eD Subdivision Name Owner's Name j-IISL--10-4 6;7_� Address ,51Q�yj� Phone Contractor's Name )=Ln 5 ljVg�}) License No. y-2 t_ Phone SLG 47i �-- "Motel❑Other : Number of living units:.------ Number of bedrooms _�...Gorbage Grinder ........_ tot Size _... .............. ................. v iJlnl .4 IV .15,nn�J1 - I l�. InIfI �rv�n w.�i�� 1JI VJn� 1..i✓. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J industrial ❑Open Bottom ❑-Manteca— Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing # Public ❑ Other Delta Irrigation Rpprox: Eastern Type of Casing Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal - ❑Other I' N Type of Grout � 1 _ Surface Seal Installed by Repair Work Done E] Type of Pump - H.P.- R .' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') t Depth ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence ''0"` Commercial _ Other Number.-of living units: Number of bedrooms Loft X Z.d ' Character of soil to a depth of 3 feet: ��L/►-y Water table depth SEPTIC TANK �j Type/Mfg 019- - �L Capacity /ZB p No. Compartments 2.- PKG. iPKG. TREATMENT PLT. J Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well—/-/04--Foundation 161 __ Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines 2 - Total length/size 1770"X2- FILTER 770'X2_FILTER BED ❑ Distance to nearest: Well Foundation /Q Property Line SEEPAGE PITS Depth Size sj 'Number 2ne SUMPS L-� Distance to nearest: Well Foundation gQ Property Line 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. 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all req -red inspections. Complete drawing on reverse side. Signed X Title: Date: 9?,O 3 F E ONLY Application Accepted by Area -I •Stk 466-678 Additional Commen / �Q Lodi 369-3621 Pit or Grout Inspection by Date 19-- -JU Manteca 823-7104 Final Inspection by Date ��3 ❑ Tracy 835-6385 Applicant -_,.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,TCA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO A ff Eli 13-24 REV, 10/82 10/82 500 14-26