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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �,� F 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1'YEAR-FROM DATE .ISSUED E (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 o. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 6 7a4�,X-a—' Job Address ii Subdivision Name Owner's NVY' ��i.= /✓ Address vide' Phone 1 Contractor's Nam 1�4:]rJJ�.l;�a License No. � 'L�a Phone 4 TYPE OF WELL/PUMP WORK: NEW WELL [*� WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR = OTHER DISTANCE TO NEAREST: SEPTIC TANK 14-C!3 SEWER LINES ;?-4�- r-' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INT€NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10,•-�, 1�}rdust-Tial rperr�Bvttvm +-Q Manteca �� �-�Dia�-of}Well Excavata.on�"� w-y--- EE. Clomestic/Private Gravel Pack Tracy Dia. of Well Casing II Public Other - Delta Type of Casing irrigation Approx. Eastern Specifications F-ICathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout 5-f-5 -a- U ether Surface Seal Installed by �►,ti� Repair Work Done ❑ Type.of Pumpi _ H.P. 57 State Work Done S Well Destruction U We11,Diameter Sealing Material (top 50') Depth Filler Material (Below 50') Q TYPE OF SEPTIC WORK: NEW.INSTALLATION Fj'= REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is :s- available within 200 feet,) OF. . Instaliation will serve: Residence _ Commercial _ Other t Number of living units: Number of bedrooms Lot size Character of soil•to"a depth of 3 feet: Water table depth SEPTIC TANK [J Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ; Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U !i'•No. & Length of lines Total length size FILTER BED ip Distance to nearest: Well Foundation Property Line SEEPAGE PITS j; Depth Size Number SUMPS U Istance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 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." IW. The applicant must call for all required i spectians. Complete drawing on reverse side. f Signed X 4�1 Title: D te: - rA 0 DEPARTMENT E ONLY £ �^ Application Accepted by Area I�/ / J Z 5 4fi6=6:781 e 7"� "+ 3 , a 7i..... Additionaomments: Lodr�+ 369-36i'1 IQ Pit or v Inspection Date (11Ma to a 823-�7{104 < Final Inspection by l Date Tri 835- 385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Bart'" OQ9, Sok:;, CA 9 2 1 - 4 �..a =FEEBASE AMOUNT DUE AMOUNT REMITTEDRECEIVED BYDATEN0.` L OS • Com'-- /z.3 oto . 10/82 500 FH 13-24 REV. 10/82 14=26 k