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i r APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HRZELTON AVE., STOCKTON', CA PERMIT NO, Telephone (209) 466-6781 DATE ISSUED =�3 PERMIT EXPIRES-1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is herebymadeto the San Joaquin Local Health District for a permit to construct and/or Install the work herein l' , described. This application is made in compliance with San Joaquin County Ordinance No. 544 for sewage or No. 1862 for well/pump and the Rules egulatons of the San Joaquin Local Health District. I� Job Address WWARD Subdivision Name / �i Owner's Name s C43er Address Phone Q y� Contractor's Name License No. PhoneT�/ TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION �Q f -PUMP,INSTRLL-AT-ION-Q Al,,..-SYSTEM-REPAIR. -:1 —OTHER-0- DISTANCE O.T.HER-UDISTANCE TO NEJRES7: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE 1 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE OF WELL PROBLEM AREA w� CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca "Dia. of Well Excavation L_I Domestic/Private F] Gravel Pack F-1Tracy Did. of Well Casing i ❑ Public ❑ Other E] Delta I ' E a Tyk--of Casing F, irrigation Approx. Eastern I' t Depth Specifications ❑ Cathodic Protection Geophysical Depth of Vbut Seal. F-1 Other., � Type of GrqutT-._. f Surface Seal Installed by 4 Repair Work'Done ❑ Type of Pump H.P. State Work Done j Well Destruction U Well Diameter Sealing Material (top 50') , ti. _ l ■1 It ;Depth Filler Material (Below 50'} , TYPE OF SEPTIC WORK: NEW INSTALLATION } REPAIR/ADDITION -(No septic tank or seepage pit permitted if-public sewer is ! available within 200 feet.) Q r Installation will serve: Residence / Commercial _ Other Number'0 living units: _ Numb' r ofbedrooms••- Lot size l� e �. Character of sail to a,,'depth of 3 feet: Water table depth ' ZJ SEPTIC'TANK-' Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ..Type/Mfg Capacity Method of Disposal fi t SEWAGE SYSTEM Distance to nearest: Well Foundation Property-Line + DESTRUCTION ❑ M LEACHING LINE # No Length Length of lines ;3 — C? Total length/size V,a !--7- FILTER FILTER BED ; Q Distance to nearest: Well Foundation Property Line SEEPAGE PTS Cj Depth Size Number 1 a SUMPS I El Distance to nearest: Well Foundation Property Line � "DISPOSAL PONDS I hereby certify that I ha.velprepared 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 4 permit is issued,,I4shall,not' employ any person in such manner as to become subject to workmanS compensation laws of California." 1 € Contractor's hiring or sON--contracting signature certifies the following: "I certify that in the performance of the work for which 1 this permit is issued;-i�I-shah employ persons subject to workman's compensation laws of California." The applicant must cal farall equir d�inspection�:-Complete drawing on reverse side. / 7 Signed Xs' . Title: _C. i�Le�c '"' ^T �- Date: ? I FOR. ARTMENT USE ONLY Application Accepted by Area Stk 4fi6-6761 t Additional.Comments: I ri' Axl :❑ Lodi 369-3621 Pit or Grout Inspection by Data �` v LL- Manteca 823-7104 oe 1 Final Inspection by-1!2k ! Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environme a Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009,, St k., CA 95201 i 6 :: k FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED-BY -DATE ,l PERMIT N0. I INFO 10/82 500 14-26