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�-M��LICATION FOR PERMIT v SAN JOAQUIN LOCAL,HEALTH OI STRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. A� Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES "1 YEAR FROM DATE-ISSUED (C pie in Tr"pl' te) NoY�Yije t� �IJL' � .ehr1- S � �. - �� herein n l Health District for permit to construct and/or install the work erei Application is ;,rreby made to the San Joaquin�oca described. This app1 cati n iS made in c mpl"ance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulati8ns dt�t�i'e,�fraa6lhjin Local Health District. Job Address CfW f '', �/5 %?c% ,&srALvH.Subdivision Name Owner's Name �..SIYyY /!9� �r�4,v Address ,70f/G�94"�j A14 �u� A�� phone Contractor's Name F />raj" y #A -$&N License No. "y�y OW Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom []Manteca Dia. of Well Excavation ' Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing Public F-jOther DeltaType of Casing LJ irrigation Approx. [] Eastern Specifications Cathodic Protection Depth " Depth of Grout Seal Jz LJ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H,p, State Work DoneCL Well Destruction ON Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 01 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ; available within 20C feet.) Installation will serve: Residence-k. Commercial Other r Number of living units: / Number of bedrooms Si Lot size /®9 's Character of soil to a depth of 3 feet: .5 9# d 4 Water table depth SEPTIC TANK Type/Mfg Rw CAsr Capacity /4400 No. Compartments -7- PKG. TREATMENT PLT. Type/Mfg ` Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well /.f0 ' Foundation 040' Property Line DESTRUCTION LEACHING LINE _ U No. & Length of lines y' 90 Total 'length size FILTER BED Distance to nearest: Wel II;t; t7Foundation /,!'0' Property Line SEEPAGE PITS ❑ Depth Size ) Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou«ty 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." The applicantt st call for all required inspections. Complete drawing on reverse side. Signed X i Title: GaiYr 9t/"or. Date: FOR DEPARTMENT USE ONLY - - -"" Application Accepted by Area [] Stk 456-6781 Additional Comments: 0 Lodi 369-3621 Pit or Grout Inspection by s. Date Manteca 823-7104 Final Inspection by Date ,/Z ❑ Tracy 835-6385 Applicant.- Return all-copies Environmental Health Permit/Services 16D1 E.,Hazelton Ave.,-P.O.. Box.2009, St k., CR 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 17 10/52 500 t EH 13-24 REV. 10/82 14-26 i 4