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R APPLICATION FOR PERNiiT SAN JOAQLiN LOCA' HEALTH DISTRICT 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3— 3_S7 e► `� Telephone (209) 466-6781 {�` ✓ DATE ISSUED Jr 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 Sa Joaquin Local Health District. Job Address AI bdivi ion Name e—R l.ZZO 42i,18a1-—5' Owner's Name L? LLOf�/c��. _Twc Address ,�e,j�� 7 �P Phone =5199 Contractor's Name AZ> �iFef'Ainp_ JLf..jAJ&nse No. ��j�./j 1f37�! Phone fff[,Jt !s��zG. w i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLLATION SYSTEM REPAIR l7 OTHER ❑ i (A DISTANCE TO NEAREST: SEPTIC TANK tl-,A;& SEWER LINES _Q�� DISPOSAL FED. �PROP. LINE FOUNDATION Al AGRICULTURE WELL ZnL-3' OTHER WELL A10 J @W PITS/SUMPS L1e1N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial U Open Bottom + Manteca Dia. of Well Excavation S'Z/ Lj Domestic/Private MTravel Pack Tracy Dia. of Well Casing 3 r� Publicther [� Delta Type of Casing 7 iD,je �j Irrigation Approx. Eastern Specifications .5 1> 1 4'-J Cathodic Protection Depth Depth of Grout Seal c I#jO G C LrA4, ❑Geophysical Type of Grout i �t Other Surface Seal Installed by �44� FAM91 -t'�a 1ZLx[n, ^� Repair Work Done Ef Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') 5 6 V DK A%1 lil A, — Depth Filler Material (Below 50') Z5 D1 /4V"ga;x TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ (No septic tank or seepage piavaimittepublic fsewer is lwithin 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 E] 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 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 workmanis compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f the work for which following: "I certify that in the performance o this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applic mus/tall or all re i in ections. Complete drawin�on verss�/ side. 1 Signed Title: f/ �,�w e2A4-/ �� Date: FOR R T USE ONLY 0 Stk 466-6781 Application Accepted by Area V _ [� Lodi 369-3621 Additional Comments: Pit or Grout Inspectio�by Date Manteca 823-7104 Final Inspection by /L(/✓✓� of- TK I 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 NO. INFO 10/82 500 EH 13-24 REV. 10/82 �5 I 14-26 ��Y`, L