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APPLICATION FOR PFR,` 7 SF.N JOAQUi" LOCAL HEALTH DISTRICT r1 3 3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. / r -6 Telephone (209) 466-6781 ! DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED (Complete in Triplicate) ' Application is hereby made to-the San Joaquin Local Health District for a permit to construct ardor 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 ,and R gulations,.of the,:San Joaquin Local Health District. Job Address 1 -)56 a� !J1 llf/I'" /2Q Subdi vision Name Owner's Name ! �� 1puYCW Address Phone Contractor's Name /19 CARCiII t License No. . Phone TYPE OF WELL/PUMP 14ORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q;d PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ x �, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open,,Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑Tracy f0 a, of Well Casing V`1 ❑ Public ❑ Other� .' '�: ❑ Delta {Type-pf,Casing Irrigation "� pprox. ❑ Eastern kSpecifications ❑ Cathodic Protection Depth ' Dept h:of.SGrout Seal ❑Geophysical Type of Grout "3* ❑Other Surface Seal Instal Ied,15y Work Done ❑ Type of Pump �•� iHaP:—"". a- +wti-- 5"rtate Work Done— Repair �- ' �!V ' Well Destruction I❑ Well Diameter �..� Sealing Materia-11(top`50')» — Depth r Filler Mate a1 (Below 50 TYPE OF SEPTIC WORK;,,-NEW INSTALLATION �J REPAIR/ADDITION ❑ �(No septic tank or seepage pit permitted if public sewer is t available within 200 feet.) G Installation w ll serve: Residence X Commercial Others Number of living units: j �Number of bedrooms Lat size ��6� S { Water table`depth Character of soil to a depth of"3 feet: AN 6y , - —/. -- v ❑ Type/Mfg . Capacity* i Ldu 'No. Compartments SEPTIC TANK r PKG. TREATMENT. PLT. ❑ � Type/Mfg r Capacity # *`Metfind of Disposall � q SEWAGE SYSTEM ❑ bistance to nearest: . Well t! Foundat4on Property DESTRUCTION LEACHING LINE No: & Length of lines 7 Total Tengt"h/size, - G Property Line 1 FILTER BED ❑ Distance-to nearest: Well (!t1 i Foundation SEEPAGE PITS ❑ Depth -{Size ,r a — £ Number SUMPS �� istance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ } { i I hereby certify that I have prepared this application and tht 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 foll�owingc• "I'certify that in the perfor ante of the work for which this permit is issued, I shall n.ot employ any person,'i.n such.mannereas•'fo becomeasubject t❑ workmani compensation laws of California." Contractor's hiring. or sub',contracting signature certifies the following: "I certify that in the perform nce of the work for which this permit is issued, I shall eI'Ta persons., ubject -to workman's compensation laws of California." } iThe applica call or, requir�d inspections. Complete drawing on reverse side. If/_ r ,.yr Title 1OLAA/t1.CA. n Date: Signed X !/H� o R DEPARTMENT USE ONLY ❑-/Stk 466-6781 Application Accepted by f� Area Lodi 369-3621 Additional Coments �`❑ m Date Manteca 823-7104 Pit oP r Grout Ins ectiion by 1, i '�'%" Date 2.� �Tracy�� 835-6385 Final Inspection by;�+ Q _ — '� / n Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ae., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �ATE PERMIT N0. INFO O^ 3 ' 10/82 500 EH 13-20. REV. 10/82 14-26