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E ��] APPLICATION FOR PERMIT E (� SAN JOAQUIN LOCAL HEALTH DISTRICT „1601 E. HAZELTON AVE., STOCKTON, CR PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED " GATE 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 Rulesd Re ulations of e San Joaquin Local Health District. Job Address WO RN'1a� Subdivision Name ti 36 ' Owner's Name 13V(2 Q4J �0"t Address Phone . ' Contractor's NameT '18 M CAR-61t 1 Rfi 9 License No. 3 /� Phone _,Z ,29 24 f/ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DE$TRUCTICN �f PUMP INSTALLATION F-] SYSTEM REPAIR OTHER DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY^E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II J Industrial U Open Bottom E Manteca Dia, of Well Excavation Domestic/Private Gravel Pack Tracy Dia, of Well Casing [ !17 Public Other Delta W Type of Casing { ' F, Irrigation Approx, Eastern" Specifications � { Cathodic Protection Depth Depth of Grout Seal Geophysical LJ Type of Grout Other Surface Seal Installed by Repair Work Done FJ_ Type of Pump H.P. State Work Done 9 Well Destruction ❑ Well biameter Sealing Material (top 501) _ 1 Depth Filler Material "(Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.40DITIONJ {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} installation will serve: Residence loCommercial Other "" Number•-fof living units: Number of bedrooms { Lot size rAeOe Character of soil tt f o a depth of 3 feet: }4- . 1 Water table depth JI SEPTIC TANK Type/Mfg 90Capacity"1 � O O No. Compartments 1 1 PKG. TREATMENT PLT. 0_,Type/ gMf = � � Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well O WeYFoundation p r Property Line 20 1 1DESTRUCTION, ❑ { 1 LEACHING LINE No. & Length of lines 0) ` Total gength/size FILTER BED r Distance to nearest: Well qP Foundation",.. _ y ' Property Line ' 4-1 SEEPAGE PITS/ ❑ Depth Size '. . ", Number SUMPS D Distance to nearest: Well Foundation NF \f;;-Property�[:ine s.: DISPOSAL PONDS y � I herebycertify that I have n • y prepared this application aii"d t"h`at�t'�ie work will be done ib 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 permit is issued, I sha,Tl not=employ`,any person in such manner as to become subject to workmant compensation laws of California." Contractgr's hiring or sub-contracting ignat'ure certifies the following: "I certify that in the performance of the work for which th"is permit is issued, Io5hal1.employ rsons subject to workman's compensation laws of California." The appl"ica callfora� requir inspections. Complete drawing or reverse side, _ Signed X � �� .,.�! Title: ou.)fjcit- Date: 7- 7� SS R D/o�ARTMENT USE ONLY 1 Application Accepted 6y , /fi t Area Stk 466-6781 Additional Comments: Lodi 359-3621 Pit or Grout Inspection'by Date U Manteca 823-7104 Final Inspection by Date� /2:1r3_ L7 Tracy 835-6385 T Applicant - Return all copies to: Environ talYHealth Permit/Services 1601 E_ Haze 1ton'Ave:, P.O. Sox 20.09, Stk., CA 95201 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED'-BY 3:' DATE 'PERMIT NO. INFO i i EH 13-24 REV. 10/82 �— 10/82 500 e" - 14-26