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APPLICATION FOR PERMIT. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3•-i Z s Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T(Complete in Triplicate) '� s 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 well/pump and the Rules and Regulativons of he San Joaquin Local Health District. Job Address l�l��° qq f_The Wt _ Subdivision Name TL&4C_0 AzA Owner's Name 01 ki PI Pi iJ ,,L co. Address 4o H ie ' C-T SAN *AM, Phone4lo"1 76( 2Z Contractor's Name License No. /;t*��7 Phonegya O$O TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE `~ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENIIED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !17 Industrial ❑Open Bottom F-1 Manteca Dia. of Well Excavation i U Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing L7 Public El Other ❑ Delta Type of Casing U Irrigation. Approx. E] Eastern Depth. Specifications Cathodic Protection Geophysical Qepth of Grout Seal (� Type of Grout Other { Surface Seal Installed by Repair Work Done [J Type of Pump N.P. State Work. Done g Well Destruction ❑ Well Diameter Sealing Material (top 501 _ t Depth Filler Material (Below 501) TYPE OF SEPTIC-WORK: NEW INSTALLATION REPAIR/ADDITION YJ (No septic-tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. �j Type/Mfg ICapacity No, Compartments -.=T F PKG. TREATMENT PLT. Q Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Q a 5 0 LEACHING LINE Kf No. & Length of lines Total length/size 4 00 FILTER BED ❑ Distance to nearest: Well 500" Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS IJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS - I�YI YYIYI� I Y YggYgp 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 certifies 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 following: "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 cal ?for all required inspections. Complete wing on reverse side. b Signed X—,9-l/U. Title: 1",444_ Date: Application Accepted by F EPARTMENT USE ONLY �, Area ��.� � Stk 466-6761 ! �� Additional Comments: Lodi 369-3621 CG.��r t Pit or Grout Inspection b °`:U&y p Y -1"�- Datean teca 823-7104 ('j(��,;ay. (J`J !o Final Inspection by i� _ Date �_ 24-� - L Tracy 835-6385 VQtJ �„3.. ho} Applicant - Return all copies to nvi nmental Health Permit/Services 1601 E. Hazelt n Ave., P.O. Box 2009, Stk., CA 952010.v dvvc avow FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I I dLJn S. coo � ` � S3 �-12SI EH 13-24 REV. 10/82 �� 10/82 500