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qfv 2_0q - 7-00-- f 3 APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. '!Rl- _7 Telephone (209) 466-6781 DATE ISSUED Z..7 j 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 and Regulations of the San Joaquin Local Health District. Job Address 17.6 ov S. A a s7yd Q b Subdivision Name (W Owner's Name G"IST/A1J tAO SS Address SA-We Phone ga3-734q 1 Contractor's Name FL XD E, "JaLlb License No. Phone 44,C-17 � v TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom r_� Manteca Dia. of Well Excavation U Domestic/Private F-]Gravel Pack ❑ Tracy Dia. of Well Casing 17 Public r_1 Other EJ Delta Type of Casing Lj Irrigation Approx. EJ Eastern Specifications F—ICathodic Protection Depth Depth of Grout Seal 1-1 Geophysical 1 Type of Grout V U Other C Surface Seal Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') d Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION I (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 a— Lot size Character of soil to depth of 3 feet: QSA A/b Z.B AM Water table depth t SEPTIC TANK [ Type/Mfg d0 -- PV-L Capacity /&V0 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation 3p' Property Line s� DESTRUCTION LEACHING LINE No. & Length of lines Z 70' Total length/size FILTER BED Distance to nearest: Well _ Foundation -Q Property Line SEEPAGE PITS [j Depth Size Number SUMPS L_1 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 must call for ll required inspe ions. Complete drawing on reverse side. n Signed X Title. Date: f d3 FOR DEPARTM 3 ❑ Application Accepted by Area Stk 466-6781 © Additional Comms: E] Lodi 369-3621 Pit or Grout ection by Date3 Manteca 823-7104 Final Inspection by �� ks-)S2, Date c — �dJL7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Helton Ave., P.O. Box 2009, Stk., CA 95201 Hazelton FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �i Zl_` 1 EH 13-24 REV. 10/82 g l�� 3 10/82 500 14-26 J