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APPLICATION FOt PER 4I ss I, SAN JOAQUi'f LOCAL HE?.LTH D15TRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT NO. I \ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED hA1 (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 t 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 n Joaouin Local Health District, Job Address ��Af?� - klrC Subdivision Name Owner's Name p LF�a�r{ 0 A.t] Address F O x O � Phone Name MI � ;? e Na. f6 qk Phone 3/- !O TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ; REQ OTHER LI DISTANCE TO NEAREST: SEPTIC TANK C j - ..�R LAlp ES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELLOTHER THER "`_""� - --- --- WELL INTENDED USE PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EJOpen Bottom Manteca Domestic/PrivateDia. of Well Excavation ;` I ❑ Gravel Pack ❑ Tracy Dia. of Well Casing t_1 Public � Other Lj Irrigation ❑ ❑ Delta Type ofCa sin Approx. ❑ Eastern g, ❑ Cathodic Protection L Depth Specifications ❑ Geophysical Depth of Grout Seal LJ Other Type of Grout f Surface Seal Installed Repair Work Done Type of Pump (J 8 N.P. P State Work DoneT(,d4Ae Well Destruc,t�ion Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') A TYPE OF SEPTIC WORK: NEW INSTALLATION ❑I REPAIR/,4DDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ ComiRercial �, Other\,, . k. r ' available within 200 feet.) Number of living units: Number of bedrooms Lot'size .' - Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑j r Type/Mfg - ` - - P Capacity *' NG. Compartments PKG. TREATMENT PLT. ❑ e Type/Mfg SEWAGE SYSTEM Capacity 6Method of Disposal ' Distance to nearest: Well Foundation ,,s ! DESTRUCTION ❑ Property Line LEACHING LINE ❑ No. & Length of lines Total length/siie FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Q Depth Size Number SUMPS hI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q I hereby certify that I have prepared this application and that the work will be ddone in accordance with'S'n 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 permit is issued, I shall not employ any person in such manner;aseto become subject to workman§ Compensation laws of California." Contractor's hiring or sub-contracting signature certifies-,16e following: "I cey th this permit is issued, rtifat in the performance of the work for which I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawl' an reverse 51de. Signed' Title: p. Date: PART Application Accepted by FOR DEMENT USE ONLYArea - t 1 Additional Comments: Stk 466-6783❑ Lodi 369-3621 Pit or Grout Inspection by onmenta�Health�P.r.ij�ser�,ices Date LJManteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies tor1601 L. Hazelton Ave P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT NO. 4 S �-� NP EH 13-24 REV, 10/82 14-26 10/82 500