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a" I - � m -APPLICATION FOR PERMIT I S ' SAN i WL IN LOCAL HEALTH DISTRICT /1�1 1601 E. HAZELTON AVE STOCKTON, CA ! f�� Telephone (209}'466-6781 PERMIT NO. PERMIT EXPIRES 1 YEAR FROM GATE ISSUED DATE ISSUED F � . I (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 Regulations of the San Joaquin Local Health District_. Jab Addressyy_ Subdivision Name Owner's Name L fa ke _ Address 3yjy�4B�.yh,Ay� Contractor's Name f;yjy p Sa H License Nps TrACY Phone No. Phone :4--7,3- %Aid TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR DISTANCE TO NEAREST: SEPTIC TANK t e-, OTHER ❑ ,, . SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial }J Open BottomManteca ❑ Dia, of Well Excavation ❑ Domestic/Private Gravel PackTrac J Public ❑ y Dia. of Well Casing r �j Other Delta fWl u' IrrigationType of Casing Approx. :[]'Easte'rn"^ a - - f ❑ Cathodic Protection I� Depth 5pecifi� catlons - } 'Geophysical Depth of Grout Sea-1 I U Other Type of Grout Surface Seal Installed by Repair Work Done 0- Type of Pump H.P, State'Work one Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) F TYPE OF SEPTIC WORK: NEW INSTALLATION YJ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is } Installation will serve: Residence / Commercial Other available within 200 feet.) Number of living units: Number of bedroomsw � Lot! size Character of soil to a depth of 3 feet: T �I•agr' '�= SEPTIC TANK Water table depth [Z Type/Mfg pJE Cs, j Gv we, •":Capacity / Ori No. Compartments .21 PKG. TREATMENT PLT. ❑ Type/Mfg : `'Capacity Method of Disposal �� SEWAGE SYSTEM �I Distance to nearest:; Well ," DESTRUCTION ❑ 4,t n} Foundation O - _Property Line .6-o LEACHING LINE No. & Length of line's'", Total length/size' 3a70 FILTER BED � Distance to nearest: Well `F Foundation f Property Line /a SEEPAGE PITSw Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A I hereby certify that-I-have- repar•ed-this application and that the work will be done in accordance with San Joaquin county I ordinances,'state laws, and rules and regulations of the San Joaquin Local Health District. F Home owner or licensed agent's, signature certifies the following: "I certify that in 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 compensation 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 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. Signed X Title: Date: 8- f -4'Y s FOR E MENT SE ONLY Application Accep ed by'� Area - � // /,(�y ❑ Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental He th Permit/Services 1601 E. HVelpto'n Ave., P.O. Box 2009, Stk., CA 95201 FEE BASF AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. INFO EH 13-24 REV. 10/82 f 14-26 10/82 500