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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - • AV 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete.in Triplicate) i 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 Joaquin.Local Health District. Jab Address 0 , 11 13,yte0A1 R TI?A4 bdivision Name Owner's Name Deq o 25-e V Address Phone if 0! q1 Contractor's Name �, ti cense No. 7 ; Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION U ' .JOMP=_INSTALLATION SYSTEM REPAIR OTHER. ❑ O DISTANCE TO NEARE5T SEPTIC TANK =.� SEWER,LINES,. ti .: }�. D15 05AL\FLD. 'sti"� ,PROP. L1NE----- r~ ;. `AGRICULTURE''WELL"` -- OTHER 4JELL PiT515UMP5 INTENDED USET rsTYPE~OFTWELL PROBLFM AREA CONSTRUCTION SPECIFICATION5 i } Industrial [J open,Bottom [ Manteca Dia.of Well_Ex'ava't on -U-Oomest'ic/Privat'e rGravel Packz. Q;Tracy - 'Dia: of.-Well Casing -\I ty Public. , , �} Other Del to- - �-` L �� r, >t =`� " TYPe�o Casing_ I.rri`ation r 'fi Eastr'rn - LI- yq f: Approx'. � E . Specjfications F _ Cathodic Protection Depth , ❑ Depth of. GroutSeali. Geophysical I Type of Grout i U Other 4-- +.s4 Surface-Seal Installed by .-,Z Repair Work Done �J ��Type of Pump P 3 > State Work Done Well Destruction U Well Diameter. :Sealingr,M terial W, 1,. {..}Depth I F]Iler Material' (Belo`w 50'} r 4 I TYPE-OF SEPTIC WORK NEW INSTA7=CATION Lr" AEPA'ffI/R'DDTT lI ~rNo s Pyr anK nr=seepaije=�it•,permi tt�d='f pubJ cYsewer�s✓, �4 available within 200+feet.) V lnsta,-ll-lat,ion will serve: Residence T/ :Commercial d Other _ Number of,I IVA units: Number aftbedrooms T "" Tot siie Character-of soil;to'a'depth of 3 feet: O 4_34F Water. table depth {_ ' No. Compartments SEQTIC TANK ; Type/Mfg �� Capacity l e-r o PKG. TREATMENT PLT. �" Type/Mfg Capacity Method of Disposal . SEWAGE ,SYSTEM Distance to nearest: Well Foundation Property'Line .DESTRUCTION L 1 r '`Y •r , LEACHING LINE No. & Length of lines E .� Total length/size i FILTER. BED Distance to 'nearest: Well Foundation Property'Line SEEPAGE PITS Depth Size *_ Number SUMPS, -Distance to nearest: Well Foundation Property,Line A. DISPOSAL PONDS ❑ s I hereby certify that I have prepared tlpis 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.th* i permit is issued, I shall not employ any person in such manner as,to become subject to workman�.compensation 'laws of"Cal"ifornia:" 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 or required inspections. Complete drawing on reverse side. Signed X 1 ,- a Title: Date`-: — ! J 1if/Jl FjDEPARTMENT USE ONLY y Application Accepted by i Area 5tk 466;6781 ' Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date �`-� y/ Manteca 823-7104�, } i Date : Tracy 835-6385rM Final Inspection by Applicant - Return all copies1:0 . Environme al He t Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,�CA 95201 F FEE 811SE AMOUNT. DUE AMOUNT REMITTED r. RECEIVED BY DATE + PERMIT NO. ' INFO f a NJ � - EH-13=24 REV.,-10/82. r 14-26