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PA ff 3-7S a� 30 14 APPLICATION FOR PERMIT p SAN JOLOCAL HEALTH DISTRICT �� _ �g 0 1601 E.°HAZELTON AVE., STOCKTON, CA PERMIT NO. ��- 3 q Telephone (209) 466-6781 DATE ISSUED 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 of the San 'Joaquin Local Health District. , Job Addre4 BR/I, W ,SubdiDision Name o w Owner's Name R(�13EX�,/ /41, Address Z17e2 -1 AL<: )M Phone �° % s•�; /Q '` Contractor's Name M6e2&�/I'f,/ A1S yj/A?L9,pcen�e No. Phone 72 Z TYPE OF WELL/PUMP WORK: NEW WELL 127 WELL REPLACEMENT DESTRUCTION❑ PUMP INSTALLATION a SYSTEM REPAIR M�� v OTHER :- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. _ ROP. LINEJ;_ 0 FOUNDATION _ � =�� AGRICULTURE WELL — OTHER WELL PITS/SUMPS �/- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it 17 Industrial Open Bottom Manteca Dia. of Well Excavation 10 Domestic/PrivateGravel Pack Q Tracy Dia. of Well Casing 10 4f 1 Public Other Delta j2,1---� - • _*� � ez: ❑ ❑ ❑ Type of Casing _ ❑ Irrigations Approx. ❑ Eastern Specifications ��O?Aj �tCathodic Protection Depth 1x , y Depth of Grout Seal "f- ❑Geophysical T Type of Grout Other .,-.�, 1 Surface Seal Installed by. Repair Work DoneE] Type of Pump _y[J(�j-_ State-Work-Done ---= - } _ �� Well Destruction ❑ Well Diameter Sealing Material-{top 4 0'); _ Depth Filler Material (Below 50')` ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is f € {" available within 200 feet.) ` Installation will serve: Residence _ Commercials Other i Number of living units: Number of bedrooms Lot size Character of soil to a depth,of 3 feet: Water table depth i SEPTIC TANK ❑ Type%Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type%Mfg;,, ,^-� °"�'� Capacity 4 Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation ' Property Line �r {I DESTRUCTION ❑ _ . ! v LEACHING LINE F-1 No. & Length of lines ° , Total lengt0size FILTER•BED F71---Distance to nearest: Well - Foundation Property Line SEEPAGE PITS `" ❑ Depth Size Number SUMPS U Distance to nearest:: Well Foundation 1'Property Line DISPOSAL PONDS A - 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 FDistrict. Home owner or licensed agent's signature certifies the following: "I certify thatA n 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 t compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that'Vn 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 all uired inspections. Complete drawing o/n'/�everse side. i Signed X Title: ��/ GG�¢ � ' ��,R Date: �' - 11 0 RTMENT USE 0 Y t �G Application Accepted by Area 'Stk 466-6781 :M_?J �O y �._ ._. ..__.. ._ --,, _ 369 _621 . Additonal`Comments:r Lodi 369-3621 Pit or Grout Ins etion b Date Manteca 823-7104 Final Inspection'by i- _ Date d L Tracy 835-6385 Applicant - Return all copies to: Environmental: e' th Permitvi ces 1601 E.-Haielton Ave., P.O. Box 2009, Stk., CA 95201 - -- -FEE BASE- --AMOUNT -DUE ~AMOUNT REMITTED -` RECEIVED4BY—I——DATE ^- PERMIT-NO: q "" INFO X33 EH 13-24 REV. 10/82 10/82 500 14-26