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aJ � APPLICATION FOR PERMIT fIJ �€ SAN JOAQliiN LOCAL HiALTH DISTRICT , L ti� 19 p3 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. i� Telephone (209) 466-6781 ' � a DATE ISSUED 01 �_ � , PERMIT EXPIRES i YEAR FROM DATE ISSUED 0.L),, �y �a } (Complete in Triplicate) ,Cr ! 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. Job AddressA1 �� 3 Subdivision Name Owner's Name Address !' 7 2(,1 Phone Contractor's Name License No. Phone TYP_El OF,WELL/,PUMP_WOAK. �NEW_WELL -.,p- _--WELL REPLACEMENT—ffl-- —DES7RUCTI N"U"""""" ' "� -- '—'' 0i . _ -z �. . _ .. - PUMP INSTALLATION STEM REPAIR 0 ER Jam. `" .` tyQ i DISTANCE TO NEAREST: SEPTI.G.TANK SEWER NES D OSAL FLO, PROP. LI E —' FOUNDATION 'r} :,` !tAGRI.CULT WLLLTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO 'RUCTION SPFCiFICATIONS j dustrial U Open#B'tfom')\ anteca 6i3,-of Well Excavation 4 U Domestic/PrivateD Graver Pack : E] Tracy Dia.of Well Casing L7 Public Other Delta '' Irrigation fs^t "�F M % , '" Type of Casing �J 9 { Approx. Easter 4 De th ❑ + ecifications _ Cathodic Protection p } y De h ofiGrout Seal { =4 L7 Geophysical _ �1 r , ` Other 4� i i s Type 1 Grout • Surface Seal Installed by Repair Work Done El Type of Pump "it H.P. State Work Done Well Destruction U Well Diameter Sea Ling Material (top 50') $ Depth I Filler`Mafe`N:l- (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIONNo septic tank;;orwseepage,pitmpermitted .if—public sewer is..;. available within 200 feet.) Installation will serve: Residence <---o'."Commercial Other Number of livi units: Number of bedrooms 77 Lot size y2. A-�rY Character of sol to a depth of 3 feet: � Water table depth SEPTIC TANK Type/Mfg P�, � ��;, Capacity 8!190 No. Compartments ~f PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal S SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ' DESTRUCTION : LEACHING LINE "'"`IVo' &.L}engtho f lines _ �.� � Totamllength/size r �learest: Well Foundation FILTER BED ;� Distanceto N � Property Lire t ` SEEPAGE PITS Depih A � Size Number I SUMPS Distance to nearest:• Well //y(� Foundation 2740 ,+�1TProperty Line 7`'— 1 ► DISPOSAL PONDS E7 I hereby certify that I have�.prepa ed�thislapplication and that thework will be done in accordance with San Joaquin county ordinances, state laws, and rules_and regulations�of the San Joa�in Local Health District, t 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"arr,( pers_84winnsuch manner as to become subject to workman,�`compensation laws'of California." ` Con fractor"s—h"iring oy sub-contracting signatun`'e certifies the following: "I certify that imh—the performance of the work for which this permit is issue shall employ persons subject to workman's compensation laws of California." j The :appl)caht,mus for all eq e linspections. Complete dra g on r se si i— Signed X �'-r T-i.tle': f' Date: 7 �/"(J F01 DEPARTMENT USE ONLY Application ,Accepted by"—j sAreaf; � 5tk 466-6781 F 1 Additional Cbmmen'ts <'` Lodi 369-3621' t Pit or Grout Inspection by .r Date ' - # Manteca 8 23-7104 y F R` 'Final In`s'pec.tio1nrby Date 7 ► ❑ Tracy 835-6385 Applicant - Return all copies" to: Environmental lien Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .FEE _ ,BASE. _ AMOUNT_DUE -�_6r 0,LNT`RFM;TT.ED - ,RECEIVED BY i i DATE PERMIT N0. 1 INFO _ .. If EH 13-24 REV. 10/82 n� + f 10/82�500� 14-26 `