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f APPLICATION FOR PERMIT SAN JOAQUIN LOEAL HE=,LTH DISTRICT 1601 £. HAZELTON AVE., STOCKTON, CA PERMIT NO-83 Telephone (209) 466-6781 DATE .ISSUED �1 _3 � PERMIT EXPIRES I YEAR FROM DOTE ISSUED (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 No. 1862 for well/pump and the Rules and Regulations of the San Uoaquin Local Health District. ; Job Address Subdivision Name N.A. Owners Name S. Bureau ot KeClamaticxmass !'..0. Box 1209 Tracy 95376 Phon420 8 e i Phone Contractor's Name License No. TYPE Of WELL/PUMP WORK: NEL! WELL WELL REPLACEMENT ❑ DESTRUCTION � (?�) + - AWXXM � PUMP INSTALLATION-F_� SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / !/ I f Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation (p 01f Domestic/Private �Gravel Pack ❑ Tracy Dia, of Well Casing Public Other Delta Type of Casing Irrigation *4' Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal �•• 1 1-1 Geophysical Type of Grout 0.— &JOther See attached letterl6l�"JX'k4 Surface Seal Installed by r ,1 k Repair Work Done Q Type of Pump H.P. State Work Done �V" Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U 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 Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK [—I Type/Mfg Capacity Na. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM m Distance to nearest: Well Foundation Property Line. DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED __J Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ " 1 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." The applicant must call for all required inspections. Complete drawing on reverse side. Date: Signed X Title: �1 041L FO DEP ENT USE DNLY rea d' 1 tkApplication Accepted b 1 -� odi 369-3621 Additional Comments Pit or Grout Inspection by Date ElManteca 823-7104 Date � Tracy 835-6385 Final Inspection by Bax 20D9, St k., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, f INFO awl 10/82 500 EH 13-24 REV. 10/82 14-26