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_; - / APPLICATIONFDR PERI !-T 42,1 SAN JOAQhiN LOCA? 'rir4LTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT ND. Telephone {204} 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicatior 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. Job Address /3 Q.-2 G ,e Subdivision Name Owner's Name ILIOZZ44A d Address S.9 m e . Phone Contractor's Name � q n�f y License No. Phone 14D TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUCTION ❑ O� PUMP INSTALLATION SYSTEM REPAIR U OTHER { vv DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Pri.vate ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [_J Other [1] Delta Type of'Casing l-i Irrigation Approx. [-] Eastern Specifications n Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout -FJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) w Depth Filler Material (Below 50') �O? TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is l� X available within 200 feet.) ^ Installation will serve: Residence Commercial Other ! P Number of living units: Number of bedrooms Lot size jrqG,_�- Character of soil to a depth of 3 feet: Water table depth �J p SEPTIC TANK ED Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line_- i DESTRUCTION ❑ LEACHING LINEi No. & Length of lines 3 Total length/sizex Z FILTER BED ; - ❑ Distance,to nearest: Well OD Foundation r Property Line r" SEEPAGE PITS Depth 'Z3- Size , 3 Number SUMPS ❑ Distance to nearest: Well `j Foundation Property Line r DISPOSAL PONDS ❑ 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 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 workmant 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." i i The applicant must cU.1 or a ir ired in ct' ns. Complete dra • g on everse sid Signed X Title: Date: q—( X83 i ORD ARTMENE Application Accepted by ' rea L3 Stk 466-6781 Additional Comments- .Lodi 369-3621 r Pit or Grout Ins ion i Date Manteca 823-1104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copie to: Enviro mental Health Permit/Services 1601 Ha elton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ,p PERMIT NO.. INFO 4 � 0� D 3— 5 EH 13-24 REV. 16/82 10/82 500 14-26 i