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APPLICATION FOR PERMIT 1 SAN JOAQL'IN LOCAL HEALTH 'DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED i 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 and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump and the Rules andRe u� E �'`� ��U Subdivision Name lations of the San Joaquin Local Health District. Job Address 1� p Gab Pau77 Pauls 3? -/ -4,7 , Owner's _PAVIS-fl/Nowes Address Phone--6-23- 3225/ Contractor's Name /1/ CAjZGlL� License No. 241M 8 Phone 2/26 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D AL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT /SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom f Mante Dia. of Well Excavat' Domestic/Private Gravel Pack acy Dia. of Well C ' g I L] Public CJ Other Delta Type of sing Lj Irrigation ox. Eastern w 5 fications � �1 Cathodic Protection ka 1 epth , Depth of Grout Seal 1-1 Geophysical t Type of, Grout U Other Surface Seal Installed by Repair Work e E] Type of Pump H. - -State-Work Done ; f1 Well Des uction U Well Diameter Ealing+Material. (top .50';) k,' i _ Depth Filler Material (Below 50') k __ 4 y 51l TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is l/V{vj available within 200 feet.) Installation will serve: Residence commercial _ Other Number of living units: Number of bedrooms 2 — Lot size ACRCS Character of soil to a depth of 3 feet: ) Waster table depth x SEPTIC TANK VH Type/Mfg P I f L Capacity Nd. Compartments 1 2 PKG. TREATMENT PLT. Type/Mfg Capacity s Method of Disposal SEWAGE SYSTEM Distance to nearest: Well .S O Foundation �4�1 _ Property Line DESTRUCTION LEACHING LINE No. & Length of lines `T7d''-•-� �,__. Total length/size`` FILTER BED Distance to nearest: - Well _50 Foundation /�� Property Line SEEPAGE PITS ❑ Depth Size _ Nomber SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 workmanb 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." j€{ The applicant ll for all required i pections. Complete drawing 'on"Fevl?r5-�?"s'i'd'e: - -__ Signed-7X f11+v Title: �t.�l1C n,, Date: 9 4OR DEP RTMENT USE ONLY s i � Application Accepted by Area �[ Q S. 46b-67$I. j Additional Comments: Lodi 369-3621." r Date Manteca 823-71041 f ,Pit or Grout Inspection by rFinal Inspection DateME. azelton ❑ Tracy 835-6385,. �__App,lacant - Return all copies toc nvironmenta'l Heait Permit/Services 16 Ave., P.O. 13ox 2009, Stk. CA 95201 rFEE BASE AMOUNT DUE ?AMOUNT,REMITTED XCE V.E➢BY,� i DATE � P PERMIT NO.NFO 1 EH 13-24 REV. 10/82 f°�n�[ W �`'i� �� 10/82 500 ; 14-26