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_ __ .r. ...�,-•.-, � .,. - ..- gip, ."�-.,o,ea� V I T11 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT ' 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F j ��,�".rr• �, Application is hereby made to the San Joaquin Local Health District for a permit to construct and r'or insioll the,work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for aeW4 0:.or-No. 1862 for'welI pump and the Rules and Regulations of the San Joaquin Local Health District, % ii- '•<�<s= t Job Address Bird Road cirmn 4g• B� a� �,�4- Subdivision Name Owner's Name Robert . Brown, Sr. Address874 E. Woo dward,Ilan teda # °Phone 2t31 239-492 � Contractor's Name % . ' License No, � T „T - +` 'Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION CJ PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE. FOUNDATION AGRICULTURE WELL OTHER WELL _.PITS/SUMPS a IMPENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --.4 tim4 � 17 Industrial ❑Open Bottom ]Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing _ �! L7 Public f j0ther ❑Delta Irrigation Type of Casing L� 9 Apprro x. U Eastern Specifications Cathodic Protection Depth - -- -- Geophysical Depth of Grout Seal _ Type of Grout Other Othe Surface Seal Installed by Repair Work Done Type of Pump _ _ H.P. State Work Done _ c Well Destruction [J- well Diameter Sealing Material (top 50"1 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is. available within 200 feet.) !� Installation will serve: Residence XX Commercial _ Other Number of living units: Number of bedrooms _2 Lot size 40 a e'er e s 114t 1� Character of ,oil to a depth of 3 feet: r gravelly L, Rib g �jgi ter tablE�depth �T _ SEPTIC TANK Type/Mfg C gar—a t Capacity M--- -- No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal i SEWAGE SYSTEM flis•tance to nearest: Well ..pj•_a! Foundation -- _ Property Line 30Q r j DESTRUCTION Q - - - l LEACHING LINE [id- No. & Length of lines 2 Total length/size FILTER BED -X.stance to nearest: Well Foundation Property Line s SEEPAGE PITS Depth Size Number SUMPS IJ Distance to nearest: Well - - Foundation Property Line DISPOSAL PONDS, 0 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 licenser! ,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 h'ring 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," l The applica must CaIT`"Frrr Lrequir.`d inspections. Complete drawing an reverse side. Signed X f , Title: _ --. d1 te: �:FOR DEPARTMENT USE ONLY --- x Application Accepted by Area [] Stk 466-6781 Additional Comments: Lodi 369-3621 , Pit or Grout Inspection by Date Mantece 823-7104 Final Inspection by Date L Tracy $35-6385 Applicant - Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,kstk., CA -95201 FEE BASE AMOUNT DUE _ AMOUNT REMITTED M RECEIVED BY DATE PERMIT ND, INFO — -W- ` A4-7 i<w_ y _ 10/82 500 EH 1314-24-26 REV. 10/82 s 1 •