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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT s Ij HAZELTON AVE. STOCKTON CA 140 2 <t' 1983 PERMIT N0. .3~ x lq J 160 i ETelephone (209) 4661-6781 �1—�G g3^e�+�+�w1j DATE ISSUED _11_ �_l� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN mDN L OILDAL RIC (Complete in Triplicate) flEALTH � ,� Application is hereby` made to the San Joaquin Local Health District for a permit to construct an)L r install the work herein. desc:ribed. 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, X Job Address 19 6 6 R E AYtr R S Subdivision Name G � X Owner's NameTHOWIAS A SARNBWQC'f Address -A 123 GOTTA ST. A,IANtlCA Phone B13 75173 Contractor's Name Oc,qN,�-12, License No. • Phone ip TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION II PUMP INSTALLATION SYSTEMS REPAIR,.., �'; „ OTHER .� j W i.,;n DISTANCE TO NEAREST: SEPTIC TANKK l y p 1 SEWER LtINES k + t DISPOSAL FLD. I EiG ' PROP. LINES FOUNDATION AGRICULTURE WELL OTHER WELL Qp PITS/SUMPS CONSTRUCTION SPECIFICATIONS ... U p � M AREA D mestic/Private .o.f _ e Pack Trac a�r �� Dia. rof-WellaExcavation- -- �--�- ' INTENDED USE TYPE OF WELL PR .......,,........ I Iomesti /T ❑0 Gravel Pack 441 I-racy Dia of-Welk single 14 o Grav 1 �Y, , Public Other �, t +�-+ "'"`"K Type of�Casing i V Irrigation , Approxi* [� Eastern �'""" " Speciifications*C Depthdr ,, NNIIII ❑ Cathodic Protection. 1 " + ` Depth of Grout Seal qpp Geophysical 1 ` _ Type of Grout Other , „1 Surface Seal Installed by �lrr Repair Work Done Type of Pump,( H.P.X 1.5* State Wo'rk"Done Well Destruction U Well Diameterf,'.' Sealing Material (top 50') 91i �- Depth IFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITION J (No septic tank or seepage pitllpermitted if public sewer is, ... available within 200 feet.) Installation will serve: Residence _- Commercial Other, Number of living units: i Number of bedrooms Lot size Character of soil to a depth of 3 feet: Waterd ltable depth CZ SEPTIC TANK` ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property ine DESTRUCTION p LEACHING LINE U No. & Length of lines Total length/size, �U FILTER BED Distance to nearest: Well Foundation Prope ty Line __ . IIIIII SEEPAGE PITS Depth Size " ti . T.ir t Number J4 SUMPS j_j Distance o neares t £F`Well ., o ndation + [ Property Line DISPOSAL PONDS ❑ � $ � 1 , I hereby certify that I have prepared this application and that the work will be done in accordalnce with San Joaquin county ordinances, state laws, and,rules and regulations of the San Joaquin Local Health District. i 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 5l,1compensat ion 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 Califo4iia." The applicant mut call for all required inspections. Complete drawing on reverse side. X Signed Xj Tit e: X QWNRA Date:�r 11 28.87 � T R MENT U NLY I� Application Accepted y Area Q� Lp Stk 466-6781 Additional Comments _ U Lodi 369-3621 t Date Manteca 823-7104 Pit or Grout Inspection by s � j-)�>� Date w"��/�� Tracy 835-6385 - F,ina1 ,Inspection by Applicant- Return all copies to: , Environmental Health Permit/Services 1601 E. Hazelton Ave., IFI.O . Box 2009, Stk., CA 95201 i �M FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEp PERMIT NO. INFO EH 13-24 REV. 10/82 A , 10/82 500 14-26 Tom/