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IOU, APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (Complete in Triplicate) 1 'A 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 Rules-and Regulations yo�Ef/�the San Joaquin Local Health District, Job Address +[ 7� 3 du 134-a r—k 1QJkdivisiorAm4_,&Ar• P® Owner's Name R Address43 =a .2 ��j�7] G� '� none Contractor's Name eh se No. Z S, 3 Phone { TYPE OF WELL/PUMP WORK: NEW WELL Q�WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ GTHER k DISTANCE TO NEAREST: SEPTIC TANK � � SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE_WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial EAt-qTen Bottom ❑ Manteca Dia. of Well Excavation �- T El,�B6mestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing " ❑ Public ,.-❑Other ❑ Delta Type of Casing z.L "1F 71 Irrigation tt3,*, Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout Seal s a ❑Geophysical Type of Grout g a-c- M ❑Other Surface Seal Installed by M'4Q-, Repair Work Done ❑ Type of Pump �_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ 1' Depth., Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ^ ; available within 200 feet.) Installation will serve::. Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t _ PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ 1 LEACHING LINE ❑ No. & Length of lines Total, length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Si e'--�T _ - Number. SUMPS ❑ Distance 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 for0hich this permit is issued, I shall not employ any person in such manner as to become subject to workman comp.ensation'"laws o-C'Cal�ifornia." € Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perf�ance of the.work,lfor which this permit is issued, I shall employ persons subject to workman's compensation laws of California. The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: t c� Dat;i% �.y'7 � c-a Vit' — �� DE ARTMEN7 USE ONLY !% ! Application Accepted by �Q,�-`r _ Area ❑ 5j k 466`6781 �- syr Additional Comments: !tJ Lodi-'= 369:3621 Fri Manteca 823-7104 i Pit rout spection Date 4� tie• Final inspection by Date L7 Tracy. .,835-6385 Applicant - Return all copies to: rvironmental Health Permit/Services 160 E. azelton Av P.O. Box;,2009a Stk., CA" 95201 =� BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, ice _ EH 13-24 REV. 10/82 Z I� 10/82 500 1 14-26