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APPLICATION FOR PERM11 SAN JOAQL'I?; LOCAL h-Z.LTH DISTRICT PERMIT N0. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I.YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby lication is mamade to the San Joaquin Local Health District fora permit to construct and/or install the work herein k de in compliance with San Joaquin County Ordinance No, 549 for described. This app sewage or No. 1862 for well/pump and the Rules and,Regulations of the'San Joaquin Local health Name 1 Job Address •� 7�- —� /�f # -./Lf 760&nne. 04 Owner's Name It?/C— Address Phone ('141 License No. � '4 Contractor's Name G ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J TYPE OF WELL/PUMP WORK: NEW WELL OTHER IJ ❑ SYSTEM REPAIR I PROP, LINE PUMP INSTALLATION SEWER LINES DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL FCONSTRUCTION SPECIFICATIONS I INTEND�E�USE TYPE OF WELL PROBLEM Open Bottom ❑Manteca Dia. of Well Excavation Industrial Dia. of We11 Casing Domestic/Private ❑ Gravel Pack ❑Tracy ❑Other ❑ Delta Type of Casing ❑ Public Irrigation Approx. Eastern Specifications ❑ ❑Cathodic Protection Depth Depth of Grout Seal OQ ❑Geophysical Type of Grout Other Surface Seal Installed by L H P State Work Done — 1 Repair Work Done ❑ Type of Pump �� Sealing Material (top 50') Well Destruction 4❑ Well Diameter Depth Filler Material (Below 50') Qf available within 200 feet.) f TYPE OF SEPTIC WORK: NEW INSTALLATION �Q/REPAIR/ADDITION U ( No septic tank or seepage pit permitted if public sewer is �f Installation will serve: Residence Commercial_ �Other / Lot size �-1a,�— Q � Number of living units:` '-� Number of bedrooms Water table depth Character of sail to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK Type/Mfg G'O/V Capacity Method of Disposal ___?_� / I PKG. TREATMENT PLT. ❑ Type/Mfg l �_/o r Property Line-�_-��V,O SEWAGE SYSTEM ❑ Distance to nearest: _/Jell Foundation 10 DESTRUCTION Total 1�gth/size Foundation-LEACHING LINE I No. &'Length of lines Property Line © FILTER BED }J Distance to nearest: Well A-01- � Size Number f SEEPAGE PITS ❑ Depth � Property Line �— _ _� SUMPS U Distance to nearest: Well Foundation DISPOSAL PONOS ❑ b certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I hereby or which this ordinances, state laws, and rules and regulations of the San Joaqui11 certifn Local Hethat alth District. k Home owner or licensed agent's signature certifison es the -folisuch o i ng- to becomeysubjectntohworkman� compensathonwlawsork fof California. t il permit is issued, I shall not employ any p the performance of the work for which ! Contractor's hiring or sub-contracting susubject re �toeworkmans the �sl9ompensation11 rlaws oftify aCalifornia ." 4 this permit is nat issued, I shall employ persons The applicant must call for all required inspections. Complete drawing on reverse side. Date: F Title: Signed X ' D ARTMENT E ONLY L� Stk 466-6781 � - Area __�� Application Accepted by ❑ Lodi 369-3621 Additional Comments: Date `-�� ❑ Manteca 623-7104 PV f eway 835-6385 F as J{Y Pit or Grout Inspection by Date _��° � ❑ Tracy Final Inspection by Applicant - Return all copies+ to: Environmental Health Permit/Services 1561 E. Hazelton ve., P.O. Box 2009, Stk., CA 9520 I DATE PERMIT NO. �1l0 6u��3/Ik;� AMOUNT REMITTED RECEIVED BY D✓0#1 4✓ FEE BEJ MOUNT DUEINFO r�Y�NF L 4 / ��• 10/82 500 syr-l-ar.. EH 13-24 REV. 10/82 \�S 14-26 r e^,