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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH LISTRICT Q 1601 E. HAZELTC14 AVE., STOCKTON, CA PERMIT NO, U Telephone (209),466-6781 DATE ISSUED ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (Complete in Triplicate) ; Application1e y i h e to the San Joaquin Local, Health District for a permit to construct and/or install the work herein described. T a n is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations s of the San Joaquin Local Health District. Job Address l�_ 11"e+ c''4 ('aLy,12 2d, Subdivision Name Owner's Nsme 1 �r p or /3 "?cyr1�-da"-p-, Address $g Phone 9gz-/45-1' Contractor's Name 0tvt1 e-I, . License,No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION 1 PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [n I� Industrial ]Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing L7 Public F-1 Other Delta Type of Casing Lj Irrigation Approx. [] Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical _ P j Type of-Grout y I` Other - '-.'' �.�. Surace Seal Installed by f, Repair Work Done ❑ Type of Pump H.P.- - '. State Work Done f Well Destruction U Well Diameter.=. - "- Sea"'i hg Materia1'7 top 50') _ Depth' r Filler'Materialj(-Below 50') ' ; Y TYPE OF SEPTI& WORK: NEW INSTALLATION U s REPAIR/ADDITiON,�,❑ (No,septic tank or seepage pit permitted if public sewer is } y"�" available within 200 feet.) Installation will serve: Residence Commercial _x Other Mmo k-�^Uit Number of living units: -___,I Number of bedrooms Lot size $�Q /I Character of soil to a depth of 311feet: 5ARJQ water table depth SEPTIC TANK Type/Mfg #_��(Mpe Capacity Igot:) No. Compartments PKG. TREATMENT PLT. Type/Mfg _ Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: hell 50 Foundation Property Line 10 V DESTRUCTION LEACHING LINE U No. & Length of lines - 70 f Total length/size 140 FILTER BED Distance to nearest: Well _A Foundation 10 Property Line W, SEEPAGE PITS F-1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line "DISPOSAL PONDS ❑ _ n 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 cd-rtifies 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 fallowing: "I certify that in the performance of}the wor0for which this permit is issued, I sfiall'employ persons subject to workman's compensation laws of California." ; I The appl IV mus call forg required inspections. Complete drawing on reverse side, Signed"R Title: !`t_ Dater 8-(/ ARTMEN,7,VSE ONLY Application'Accepted b ` Area (� Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit;or Grout Inspection by Date LJ Manteca 823-7104 Final Inspectionsby _� Date {� Tracy 835-6385 Applicant --Return all copies nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 i> FEE BASE AMOUNT 'DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT .NO. r INFO i�] 4S "33 10/82 500 EH 13-24 REV. 10/82 14-26