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L APPLICATION'*FOR PERMIT:' '7 SAN JOAQUIN'LOCAL.HEALTH-DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. U 6 Telephone{209) 466-6781 DATE ISSUED Z.3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San.Joaquln 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 theltan Joaquin Local Health District. Job Address 0kM:- - l,�i / :' f7i��" Subdivision Name Owner's Name rt3C'jLv/z ;W10' Address Phone Contractor's Name /j'`Y S66,1W License No. �-^ ,� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ aJELL,REPLACEMENT DESTRUCTION,❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4-1 DISTANCE TO NEAREST: SEP T-I•C TANK SEWER,LINES DISPOSAL FL-D�-��"" PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial # ❑Open Bottom ❑Manteca Dia. of Well 'Excavation k ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public i ❑Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑ Eastern Depth ti t P di th CSpecifications x-^�-------^ Cathodic Protection❑ Depth of Grout Seal ❑Geophysical a � Type of Grout ❑Other ' Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done U` Well Destruction ❑ We1T Diameter 1 Sealing Material (top 50') _ d Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION_,...-REPAIR/.ADD.ITION ....(No septic tank or seepage pit permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence X Commercial Other, Number of living units: Number of bedrooms �' Lot size �7'40 ;)PC fQ Q 3 Character of soil to a depth of 3 feet: C:4.dTyr Water table depth _ d SEPTIC TAMC ❑ � Type/Mfg ?' Capacity No. Compartments PKG. TREATMENT PLT. ❑ ? Type/Mfg 1 :..' - ':"� ;Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Found ti ' Property Line DESTRUCTION El1 LEACHING L114E ❑ No. & Length of Ines Total length/size FILTER BED ❑ f Distance-to nearest: Well Foundation Property Line SEEPAGE PITS { Depth 1.�-, ' Size, _ ° . ....----Number _/ ' " 4 SUMPS IJ Distance to nearest: Well /dt/sL Foundat'ion� - �as , PCO or Line JxT.-s 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. i Home owner or licensed agent's signature certi-fies thefollowi.ng: -"d-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 becomersubject 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, F shall employ persons subject to workman's ompensation jaws of,rCalifornia. The applican ust call for all regg4r_ed inspections Complete drawin .on reverse side. Signed x Title: -`o- 3 Date: / 4 1f FO EPARTMENT US LY, Application Accepted by Area (� <Stk 466-6781 Additional Comments: e/ ❑ Lodi 369-3621 Pit or Grout Inspection by ate 1� Manteca 823-7104 Final Inspection by Da e y 7 Tracy 835-6385 Applicant - Return all c to 4-r-onmen-a r ea- -Permit/Services- 60•-E:-44a a ton;Ave P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE' . AMOUNT REMITTED RECEIVED BY 22DATE PERMIT NO. I INFO EH 13-24 REV. 10/82' 10/82 500 ' 14-26