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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED I e,/4yV83 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED complete in Triplicate) Application is herebmade to the n Joaq n Local H alth 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 and Regulations of the San Joaquin Local Health District. oQ Job Address -041P .AAM!ETP_J,,Jr RD Subdivision Name W Owner's Name B Ee& -,d,1 5?7)2,W ZZU4AL��ddress Al,&B e I All, Phone � Contractor's Name G'LVYP Z, W&Lb License No. Y2ry7, Phone 4/6x,-3971 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ D PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing ❑j Irrigation Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done w ., Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') N 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 f"" Other� o Number of living units: Number of bedrooms Lot size Character of soil to depth of 3 feet: _1 4.1lp Water table depth SEPTIC TANK V Type/Mfg Capacity I Wo No. Compartments 7--- PKG. PKG. TREATMENT PLT. T e/Mf Capacity Method of Disposal YP 9 SEWAGE SYSTEM Distance to nearest: Well 0 FJ Foundation 10/ Property Line Tt o DESTRUCTION � / LEACHING LINE (J No. & Length of lines r" � Total length/size -�..�$� 2�� FILTER BED ❑ Distance to nearest: Well 7_jtt Foundation 2�0 Property Line SO r SEEPAGE PITS ❑ Depth Size Number (� SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 02 3 B2 S-Ys S -- / .o T f1.4AA1. .4r hkW S'c (� 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 p employ an permit is issued I shall not em to person in such manner as to become subject to workman compensation laws of California." Y 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 call for aIl requir d inspec s. Complete drawing on reverse side. Signed X s- Title: Date: �,� 0 P TMENT Xy ONLY Application Accepted y Area _ ❑ Stk 466-6781 Additional Comments:(-`-, Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - "Return all copie to: Environmental He th Permit/Services 1 01 E. Hazelton`Ave., P.O. Box 2009, Stk., CA 95201 rINFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. o I Z �s3-11 o I EH 13-24 REV. 10/82 10/82 500 14-26