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APPLICATION FOR PERMIT SANS JOAQUir, LOCAL riFALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address p? a ,r2 BaSubdivision Name Owner's Name wig - Address q�6 -:!5. 9 Phone Contractor's Name AVO Sii&�,;� License No. ..fsd Phone9- (� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F—lIndustrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public Ej Other EJ Delta V IrrigationType of Casing Q Depth Eastern Specifications [ Cathodic Protection 1-1 Geophysical Depth of Grout Seal EJOther Type of Grout Surface Seal Installed by Repair Work Done E_J Type of Pump H.P. State Work Done (b r Well Destruction ❑ Well Diameter Sealing Material (top 501) 5 Depth Filler Material (Below 501) y TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitte�if public sewer is Installation will serve: Residence Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �V_ Type/Mfg AfttAO, Capacity - jta&j!S) No. Compartments PKG. TREATMENT PLT. EJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest; Well Foundation f Property Line DESTRUCTION ❑ - p y O LEACHING LINE No. & Length of lines /4w 40 — Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ��) #' Property Line ,f�® SEEPAGE PITS Depth p �Q Size f / Number SUMPS �� Distance to nearest: Well ! Foundation _;Cgro f 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 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, I shall employ persons subject to workman's compensation laws of California." The applica .' c for al re it inspections. Complete drawing on reverse side. Signed X Title: y ,R 4�dd� F �ildE�.rdsT� Date: f2-7-JXi9 D ART NT USE ONLY Application Accepted by �,/ Area '�* � Stk 466-6761 Additional Comments: /// Lodi 369-3621 Pit or Grout Inspection by I/. Date y ILl Manteca 823-7104 Final Inspection by Date 1 Tracy 835-6385 Applicant - Return all copies to: Environ ectal Health P it/Services 1601 E. Ha el ton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO S qS_ n, I L-1--g3 / W D 93- 13371 EH 13-24 REV. 10/82 pct 4 t�(/tcC(� l0�`� 10/82 500 14-26 I�