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APPLICATION FOR PERhi1T SAN JOAQUIii LOCAL HEALTH 'DISTRICT 1' 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. ?q- 1601 + ' Telephone (209) 466-6781' 1 GATE ISSUED i_"L_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a 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 well/pump and the Rules d R ulatio s of th San Joaquin Local Health District. Job Address 0 � 'RFneh RoAA{,�,Qior Name Owner's Name �N7 L GCs s Address �5,qm=' Phoneq2 6� Contractor's Name / C 441/t. License No. 29 9/ $ Phone TYPE OF WELL/PUMP WORK: NEW WELL F-1 WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR,, U OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " DISPOSAL FLO. PROP. LINE r 'FOUNDATION— _ -AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF`WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial U Open Bottom ❑ Manteca pia. of Well Excavation G ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Public L-i Other Delta Type of Casing Li irrigation Approx. Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑OtherSurface Seal Installed by Repair Work DoneEl Type of Pump H.P. State Work Done . Well Destruction D Well Diameter Sealing Material (top-50') Depth Filler Material (Below 50') o TYPE OF SEPTIC WORK: NEW INSTALLATIONI REPAIR/ADDITION U (No septic tank or seepage p public sewer is it permitted if available withi200 feet,) a Installation will serve: Residence Commercial �qOOther d Number of living units: _,L_ Number of drooms rC Lot size S p�R�J Character of soil to a 'depth of 3 feet: of table depth SEPTIC TANK k] Type/Mfg PRI C Capacity 1,200 No. Compartments 2 k PKG. TREATMENT PLT. L] Method of Disposal Type/Mfg Capacity P SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ t length/size I LEACHING LINE X9 No. & Length of lines /�` Total 0 � FILTER BED Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS � Depth Size Numberwf SUMPS Distance to nearest: iWell.._ FblXda"tion ""prdperty'Line DISPOSAL PONDS ❑ �.:. ►.,«.__ __. .r...�... -. --^ _ .._ s .. _ 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'_Ticensed,agent's signature certifies the fol lowing:' "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such.mannerTasto become subject to workmans compensation laws of California." f Contractor's hiring or"sub contracting signature certifies the'folowing: "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 al 1 equired spections. Completc drawing on reverse side. r Signed X eCA Title: w ,•:� Ng(� Date: I' ! ^ z F' PARTMENT USE'ONLY i ? Stk 4fi6-6781 Application Accepted+by ,Area i Lodi 369-3621 Additional Comments: Pit or Grout Inspectio by Date Manteca 823-7104 Final Inspection by ' �/�/!R✓V Date ]� L Tracy 835-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 ' �__ _ -FEES.. .-BASE,..,.. AMOUNT. DUE AMOUNT REMITTED _ a„RECEIVED BY„ DATE. PERMIT N0. ........... t INFOso 10/82 500 EH 13-24 REV. 10/82 14-26 r