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3--7T APPLICATION ,FOR PERMIT R SAN JOAQUIN LOCAL`HEALTH DISTRICT g g V 1601 E.NAZELTON AVE., STOCKTON,-.CA PERMIT NO. Telephone (209) 466.-6781 �� DATE ISSUED --��-rLj \., PERMIT EXPIRES'1 YEAR FROM DATE ISSUED" IVJr` (Complete in Triplicate) ' 1 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 of the San Joaquin Local Health District: Job Address/ Bq&,�[� /P Subdivision Name ' Owner's Name AQ49E, 7— 61�/N j Address Phone 93f IZW9 Contractor's Name M dmf', �IV'S Vil,,9]1icense No. `' Rhone TYPE OF WELL/PUMP WORK: NEW WELL J21 WELL REPLACEMENT ❑ DESTRUCTION [ ; " PUMP INSTALLATION SYSTEM REPAIR -� OTHER ❑- w T--_.- � .! J DISTANCE TO NEAREST: SEPTIC TANK -� — SEWER LINES DISPOSAL FLD. LidPROP. "LINE 0 ¢ FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial Open Bottom ❑Manteca Dia. of Well Excavation 10 Domestic/Private Poravel Pack ❑Tracy Dia. of Well Casing Public Other ea ❑ ❑ h� ❑Delta Type of Casing rA Eastern / U_ Pbli�Iriation 9 �Approx. ❑EtSpecifications Cathodic Protection Depth t• •_ i ❑ 1;_�* `, Depth of Grout Seal ❑Geophysical ` Type of Grout ❑(Otherr Surface Seal Installed by y Repair Work Done �] Type of Pump"_'�/, ,_- P.H.P._ . - — State-Work -Done -- p = , y Well Destruction ❑ Well Diameter Sealing Material (topti,X50')i�, _ € Depth Filler Material (Below 50')t 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•!-� Other ` Number of living units: ° Number of bedrooms Lot size # Character of soil to a depth'of 3 feet: Water table depth « SEPTIC TANK [ Type%Mfg a Capacity W A No. Compartments =. PKG. TREATMENT PLT. ❑ Type/Mfg,,. r--�- x---w- "`"r Capacity Method of Disposal , t SEWAGE SYSTEM Distance to nearest: Well Foundation i Property Line '11 DESTRUCTION E] _r _�. _ __»• -"--�- ; Y 11 LEACHING LINE [� No. & Length of lines ' ��* "Total Iength%size FILTER BED — R—Distance to nearest: Well Foundation Property Line SEEPAGE PITS ^"`" f-1Depth Size Number SUMPS U Distance to nearest:" Well Foundation -` , Property Line DISPOSAL PONDS ti { 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'bistrict. Home owner or licensed agent's signature certifies the following: "I certify thatA n the performance of the work for which this i permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." i Contractor's hiring or sub-contracting signature certifies the following: I certify that"th 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 mu all or all1 wired inspections. Complete drawing on erse side.F Signed X / "r' Date: �� _ Title: � -�� - D RTMENT USE 0 Y Application Accepted by Area "�--- �Stk 466-6781 �/7 9�0L y. Additional_CommentS:v ❑ Lodi _369_-3621 `k " '- -` _ �/ Manteca 823-7104__. Pit or Grout b Date � `' `�. Date Trac 835-6385 Final .Inspection'by ❑ y Applicant- Return all copies to: Environmental+ e' thPermit/Sery cesi1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 - --." -FEE- - BASE-- • AMOUNT -DUE- AMOUNT"REMITTED a RECEIVED,BY-'-` --DATE- •PERMIT NO. INFO �3 �S P EH 13-24 REV. 10/82 10/82 500 14-26 �