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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO"�_ r° s Telephone (209) 466-6751 DATE 15SUF0 ' - PERMIT EXPIRES 1 YEAR FROM DATE I$SOED (Complete in Triplicate) r '; Application-is hereby made to the San Joaquin Local Health District fora 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 we1T/'pump V' and the Rules and Regulations of theSanJoaquin Local Health District. ) ,.Job Address 43 ,95 Fr'sjsb c,lc _ , Subdivision Name -cam b f' Owner's Name XjWr ��eAddress !(. 3 ) 9 ,- s eencKs�RG/ Phone _ �1��- L�?l.�t 1 Contractor's Name A•1.- Fu{.1. License No. .2 755,8 Phone 8S8-51a�1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ra DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES N '4DISPOSALSFL`D. PROP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L! F` - Y= --o-..-v-....-+r_-�».. w�-,..r... ..s-..�Y. ...d..........�r.,,...�-............-..mss-.. -..�-•� _ ,� ]NT ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial U Open_ Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing Public ❑ Other ❑Delta tj Type of Casing Lj Irrigation , Approx. ❑ Eastern Specifications € ❑ Cathodic Protection Depth Depth of Grout Seal ...p, ❑Geophysical Type of Grout P ' �vw.-,. �..... LJ Other Surface Seal Installed by I Repair Work Done El Type of Pump'• N.P. State Work Done k i Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 ,� Depth ,, Filler, Material (Below 50'} CA TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION Y (No septic tank or seepage pit permitted if public sewer is S r available within 200 feet.) { , Installation will serve: Residence X Commercial _ Other _ Number of .living units: �_ Number of bedrooms 3 Lot size 1.2(o.X M Character'of soil to d depth of 3 feet: ',,7�1`l4d Water table depth SEPTIC TANK Fy— Type/Mfg P Capacity SAO O No. Compartments ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of,Disposal, SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line. DESTRUCTION ❑. .r .' ,.." -- "`_ '" "'. '' .'.' p Y ` .{ LEACHING LINE ❑ No. & Length of lines I Soo 5a rr Total length/size /Q 1( 37 0 12'1 � F`r p'd'",S6a�` i N-," -,a �i+! �F floc(" FILTER BED J Distance to-nearest: Well 50 Foundation /O Property Line SEEPAGE PITS. L1 Depth i ' x Size Number . . i. . SUMPS A +i 1t "� {❑., e Distance to nearest: Well Foundation € Property Line DISPOSAL PONDS ❑ r aKz `. "�"".'._^, ;K"" r hereby certif that I have prepared this a lication and that the work will 'be done in accordance with San Joaquin county I Y Y . P P PP , 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-fthat 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 workmdnt.compensation Taws of California." Contractor's hiring or sub-contracting signature,certifies the following: "I,certify that in the per of the work for which this permit is issued, I hall employ persons subject to workman's compensation laws s of California.", The applicant must ca forrequ;i e" inspections. Complete drawing on reverse''s'ide'.` Signed X Title: ��,w✓jrCrL� _ Date': E TMENT�1 ONLY Application Accepted Area � ❑ Stki 466-6781 5 Additional Comments:(—/ `I [:] Lodi 369-3621 t. Pit or Grout Inspection h,,. - Date ❑ Manteca 823-7104 i' , s Final Inspection by Date Tracy• 835-6385 Appl icant - Return all copies to:;4Envi"ranmeh al"Hea'1'tti"Permit/Servi6e's 1601-.E-. zehton ve --P:O:,Box 2009, Stk., CA 95201 F.EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO O.n j4s. EH 13-24 REV. 10/82 30/$2 500 14-26 , c S