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�t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 7 Telephone (209) 466-6781 PERMIT N0. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED -3 (Complete in Triplicate) I 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 compliancewith San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules nd Regulations of the San Joaquin Local Health District, Job Address S 4 b-1 Subdivision Name �A e ialll c�3 Owner's Name C Address Contractor's Name 'IT 7_TQA Phone 433' y� License No. — 2 Phone TYPE OFIWELL/PUMP WORK:� NEW WELL WELL REPLACEMENT OESTRICTION PUMP INSTALLATION SYSTEM REPAIR OTHER ^ � + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES W # DISPOSAL FLD, # PROP, LINE ! _ `FOUNDAI.ION_�. AGRICULfiIRE WELL .. *"� �' � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI CIFICATIONSIndustrial NSPF _ oi€' LDia. of Well Lt Open Bottom Manteca Excavatis U Domestic/Private _ , p Gravel Pack Tr PublicDia. of Well Casing , y - (] Public ' ❑ �] Delta f ; {j Irrigation Other ation Type of Casing ; } } Approx. 0 Eastern (� 1 []cathodic Protection Depth ',;, Specifications ] 0 Geophysical,_ Depth of Grout Seal ' LJ Other Type of Grout 1 1 Surface Seal I�stalled by E Repair Work Done �] Type of Pump _,H.P. State Work Done �' "•�s+ Well Destruction U Well Diameter " Sealing Material (top 501) Depth FiTler Material (Below 501) I TYPE OF'SEPTIC WORK: NEW INSTALLATION ~REPAIR/ADD1 ON ' �J (No septic tank or seepage pit permitted if Public sewer is Installation will serve: Residence Commercial-: '' ,Ather available within 200 feet.) -Number of living units: / -,Oli s 7 g Number of bedrooms � 1 _ Lot size Character of soil to a dep h of 3 feet: 4F ,, SEPTIC TANK ,;.water tab*lee''depth r' , Type/Mfg CapacityNo,tCompartments i PKG. TREATMENT PLT. Type/Mfg t T h Capacity Method of D 5posal SEWAGE SYSTEM. Distance to nearest: Well , DESTRUCTION ❑ Foundation .,�-Proper-ty-,L.ine�M� t LEACHING LIiVE U No. & Length of-lines" Total length FILTER .BED Distance to"nearest: Well Foundation + I A'- �',, '.Property Line t SEEPAGE, PITS LD Depth y Size Number SUMPS t ' U Distance to n arest: Well Foundation Line DISPOSAL PONDS Property.�� '�"�`'� � I hereby certify that 1 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 o4ner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permitiis issued, I shall not employ any person in such manner as to become subject to workmans compensat,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 p6rmit is issued, I shall employ persons subject to workman's compensation laws of California.." The applicant must cal for 1 required inspections. Complete drawing on reverse side. t` ' L Signed sX 'r- �, t s # Title: _ Date: FO EP T USE ONLY Application Accepted by { Area 40 7 1 1"•` f t Stk j 466-6781 Additional Comments: Lodi 369-3621 ' Pit or Grout Inspection.by OfP Date } ❑ Manteca 823-7104 }Final Inspection by a Ti Date 3; � l-Mracy- 83E5-6385 Applicant - Return all copies to:. Environ n �He.lth 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 E BASE A INT DUE AMOUNT REMITTED RE NFO CE3VEDr6Y "- DATE PERMIT N0. IFE t -- . � Ji— EP73_W_R_67fo_/B2_—..�_....�„„m,,,,�,._,,,-__..-_Y.�,„....,.,��J�;`,��:�.:_a...� ._ 14-26 -�,- 1.0/82^-500 .