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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT aQ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, J 3 .z Telephone (209) 466-6781 DATE ISSUEDr O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, , ILI- (Compl in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or irsta 1 the work hei 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 aoaquin Local Health District. Jab Address L �V E �� Subdivision Name Dwner's Name: .IE,�- F pl!`�. Address - Phone a r F Contractor's-Name` L[,E. _RLI wLicense No, 35 1' �� ..� _ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL{REPLACEMENT t7 iDESTRUCTION O\ PUMP INSTALLATION SYSTEM REPAIR �� } ' OTHER LJ y W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. € PROP. LINE 1 EOJNDATION AGRICULTURE WELL'`"- `:i OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ��F7] Industrial - � U Open -Bottom 0-Man`t`eca—Dia:d-f-Wel'1"`Excavation 1V" LJ Domestic/Private .� Gravel Pack F-1 Tracy Dia, of Well Casing } Vi y i] Public E] Other Delta . . ' ;1 -Type "� ypee of-Casing V Irrigation Approx. 'Eastern y j Depth Specifications Cathodic Protection �. Depth of Grout Seal i U Geophysical ` 4 Type of Grout 3 [_J Other Surface Seal .Installed by Repair Work clone Type of Pump , H.P. State Work Done Well Destruction U Well Diameter _ 'a.s�"w 'Sealing Material (top Depth 7 Filler Material (Below 50') TYPE OF SEPTIC W N£W_INSTALLATI L1PRhR/,4D0[TION Lf (No septic tank or seepage pit permitted if public sewer.is available within 200 feet.) s Installation will servei*�Residence �/ -Commercial } Other " Number of living units: Number of bedrooms i Lot sizeCharacter of soil to a d 3 feet: ee �s� _ `water table depth A y SEPTIC TANK Type/Mfg Y — -Ca"pacty No. Compartments PKG. TREATMENT PLT_ C Type/Mfg M .b- _ ' Capacity Method of Disposal fr�SEWAGE SYSTEM Distance to nearest: .IJell f Foundation Property Line 2s- t DESTRUCTION LEACHING LINE No. & Length of lines - Total length/size f FILTER'BED Distance to nearest: Well ��_ Foundation Property Line O SEEPAGE"PITS Depth Size _ 3 ' t Number SUMPS U Distance to nearest: Well S�_T�' Foundation "r Property LineaiA I DISPOSAL PONDS ❑ i } I hereby certify that I have prepared this application and that the work will be done in accordance wi-t _Sar-JMt}M_n COifrrt7 'ordinances, state laws, and rules and regulations of the San€Joaquin Local Health District. Home owner or licensed agent's signaturelcertifies 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 l; 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 ermit is issue I shall em loy persons subject to workman's compensation laws of California." The applic t all fo all uire an ctions. Complete drawing on r ase sid i, Signe Title: Date: c ! Application Accepted bye OR USE .ON LY Area Stk 456-6781 s Additional Comments: `� ✓ Lodi 3 9-3621 ' Pit or Grout Inspection b Date !��'�/ LJ Manteca 823-7104 i Final Inspection by Date - 3 Tracy 835-6385 _ lR�� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT.. DUE AMOUNT REMITTED RECEIVED BY UATE PERMIT N0. INFO r EH 13-24 REV. 10/82 r� �] 10/82D 14-26 C _rl l 1