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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ,3 a"' )J 1601 E. HAZELTON AVE., STOCKTON, C FYEM1 f NO. Telephone (209) 466-6781 D E L Vr' _ - � DATE ISSUED 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 Ensruc nd,o r iIsta 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 Regulations of the San Joaquin Local Health District. Job Address A t-PA k`,57 /_Z�D Subdivision Name Owner's Name Address r19,A/, AZ,&A16- ;Rp 5'7-.1,GK_r0M PhoneL-657- OF", Contractor's Name(5165OA/ W67a_ f�E?l6.."Ae License No. Phone 517 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK /00 SEWER LINES DISPOSAL FLO. 3 PROP. LINE /0 FOUNDATION AGRICULTURE WELL --- OTHER WELL 3,12 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 JJ Industrial N Open Bottom Manteca Dia. of Well Excavation /0,{i 1=/1CST Q Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing 8 If Public F-IOther Delta Type of Casing 5 ZTG Lj Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal (7 Geophysical Type of Grout 47$i9C' IF,/ r GRV4r7_ I_J Other Surface Seal Installed byCf7,1401 pM /y(/W(�Zl.PfCGlA%fj Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [1 Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 i t 11 f r 1 required inspections. Complete drawing on reverse side. Signed X ? Title: Date: / DE ZTMFNT USE ONLY Application Accepted by Area 4� /I Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by /�jLc.✓` /`/ •— Date _7//ley D Manteca 823-7104 Final Inspection by _J/ C n_- Date �� Tracy 835-6385 Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26