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APPLICATION FOR PERMIT li SAN JOAQLi,i LOCA-_ HEALTH JT 2 7 r93 1601 E. HAZELTON AVE., STOCKTON, CA JULU 9'"� PERMIT N0. Telephone (209)466-6781 "a' e-rH QU N' LOCA DATE ISSUED �/Z7iS3 PERMIT EXPIRES 1 YEAR FROM _7V&LDATE _ micT (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 Reg(ullations of the San San Joaquin Local Health District. Job Address 7 (1 l Ilia Subdivision Name q Owner's Name C Address 2 5��,Y A �Lua - /1 Phone D / Contractor's Name License No. 7.3 Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER 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 Industrial ❑Open Bottom []Manteca Dia: of Well Excavation u Domestic/Private F_j Gravel Pack Tracy Dia. of Well Casing ❑ Public CjOther ❑Delta Type of Casing IN\ Lj Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal C-31 ❑Geophysical Type of Grout ❑Other Surface Seal Installed by f�b Repair Work Done [J Type of Pump ,dam�cZeP. State Work Done �, 6�4 /�i �•7"L�t M¢A�IS+�e V•� Well Destruction ❑ Well Diameter Sealing Material (top 50') — p filler Mat rial (Belo�,50')f (� e th /. 01 AZ'19 Zia TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage piavaermitted ifpublic fseter isilable within 200 Zts Installation will serve: Residence — Commercial _ Other Number of living units: Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments G PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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 suchFinannernas to become subjectthat ntohwopkman� compensaterformance of honwlawsfof California." permit is issued, I shall not employ any p 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 all required inspections. Complete drawing on reverse side. Date: F Signed X e �. i Im eA,n..L ( /� Title: FOB, DEPARTMENT USE ONLY 466-6781 Stk Application Accepted by v I// Area 44 ❑ - Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection by Date Final Inspection by Date-�-� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. I INFO �iS s o 10/82 500 EH 13-24 REV. 10/82 14-26 s