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1 ' APPLICATION FOR.PERM IT ` SAN JOAQUIN LOCAL H-LALTH DISTRICT 1601 E. HAZELTON AVE.,0STOCKTON, CA PERMIT N0. [[[ Telephore (2C9).466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! (Complete in Tri Plicate) Application is'hereby made to the Sari 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 San Jcaquin.Local health District. s 3�� r A, jY�c Subdivision Job AddresName Z.*9/9 Ce icr�r�T Address IPl7er �� Phone Owner's Name e < Phone S.�3"e,`x Contractor's Name 1.vT/iey License:No. �/Y v5r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑_ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS • INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial [—I Open Bottom ❑ Manteca Dia. of Well Excavation ; ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy tea. Oia�of Well Casing ` t F] Public ❑ Otherf Delta❑ Type of Casing k ❑j Irrigation Approx. ❑ Eastern Specifications ❑Cathodic t $Protection Depth # i Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done DType of Pump H.P. ' ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') prmittd if E� sewr TYPE OF SEPTIC WORK: NEW INSTALLATION F[ REPAIR/ADDITION (No. septic tank'or seepage piavailableewithinu200cfeete} is r Installation will serve: Residence L Commercial i Other Number of living units: ___L_ Number of bedrooms 2 Lot size Water table depth Character of soil to a depth of.3 feet: u'9.'a ` Capacity No.. Compartments # SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Capacity i Property Line SEWAGE SYSTEM ❑ Distance to-nearest: Well !�� _ Foundation ' ` DESTRUCTION iU No. & Length of lines i Or. Total length/size LEACHING LINE 9 FILTER BED ❑ Distance to nearest: Well 100 Foundation) �r> ' Property Line o Number SEEPAGE PITS ❑ Depth Size SUMPS W Distance to nearest: Well r oa ' Foundation `�� Property Line v 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 in such manner as to become subject to workman compensation laws of California." permit is issued, i shall not employ any person 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, pate: % Y Signed X �/�� r Title: — AlaO�t [yIARTMENT USE ONLY Area _J� ❑ $tk 466-fi781 Application Accepted by /4�✓� /]/ ❑ 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 H Permit/Services 1601 E, Hazelton Ave., P.D. Box 2009, St k., CR 952.01 FEE BASE eOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 EH 13-24 REV, 10/82 14-26 T,