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APPLICATION FOR PERMIT SRN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HA7ELTON AVE.,`STOCKTON, CA PERMIT NO. �; Telephone {209} 466-6781 � DATE ISSUED PERMIT EXPIRES I 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. T p rc ion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump ' and the Rule r R +l ns��i]te San J0�puin Local Health District. . Job Address VA.wifte Irsus" Subdivision Name Owner's Name B `v QILP ✓ Address i one Y Contractor's Nam _ License No. `~ Phone A ,3 TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUCTION 4 PUMP INSTALLATION 7] SYSTEM-RE-PAI•R,—[J = - —OTHER•-C-3-- r DISTANCE TO NEAREST: SEPTIC TANK!E SEWER LINES DISPOSAL FED. PROP....L-INE ; FOUNDATION 1 AGRICULTURE WELL OTHER WELL - PITS/SUS " .i MP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial/ U Open Bottom Manteca Dia, of Well Excavation U Domestic%Private Gravel Pack Tracy Dia. of Well Casing Qh r { Public E Other, Delta �,, Type of Casing 6 Lj Irrigation �,'Approx. Eastern jDepth Specifications Cathodic Protection Geophysicalr ` Depth of Grout Seal. Type of Grout F-11/Other <x ,� � Els (Surface Seal Installed by lip ! Repair Work Done FJ Type of Pump H.P. StateWorkDone Well Destruction LJ-iw We]l•Diameter Seal ngs'Material' (top 501) ._ Depth ,3y I Filler Material.(Below 50') TYPE•OF•.SEPTIC WORK: NEW INSTALEATIONPe4 REPAIR/ADDITION U (No,$eptic tank or seepage pit permitted if public sewer is 1 ^^^-- 1 1 1 "1 available within 200 feet.) IN a Installation will serve: !Residencq" Commercial I Other y:• ' Number of living units: h Numberof b droomsu_ Lot size t Character of soil to a,depth ,'of 3 feet: Water table depth h SEPTIC TANK - i Type Mfg Capacity af7 No. Compartments PKG. TREATMENT PET. Type/Mfg Capacity Method of Disposal ' SEWAGE SYSTEM c-1 Distance to nearest: Well Foundation Property Line. DESTRUCTION +--L 1 LEACHING LINE U No. &'?Length of lines — Totaljl ngth/size / I �-f I FILTER BED � Distance to nearest: Well �p Foundation ��_ Property Line 3 4 SEEPAGE PITS Cj Depth! Size Number SUMPS 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 d6Ffifll s'the following: "I certify that in the performance of the work for which this permit is issued,,I.shall not employ any personjin such manner as to become subject to workman§ compensation laws of California." <"""c ntractor's H-iring,or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall a 'joy#persons.subject to workman's compensation laws of California." The applica t must call for al lr quire inspections. Complete drawing on reverse side. IT Signed Title: Date: r F DEPA T NT USE ONLY Application'Accepted'by""_ i I��✓' """'Area- 1 ��Stk�.... 466-67.81 .� ., Additional Comments: L!-�- Lodi 369-3621 Pit or Grout Inspection by Date Ll Manteca 823-7104 I Final Inspection by Datef ❑ Tracy 835-6385 Applicant - Return all copies to: Environ Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952D1 r FFE ;6ASE �OjU/NTi DUE AMOUNT REMITTED RECEIVVED BY DATE PERMIT NO. O �. a- �. fy 1 10/82 500 `� EH X13-24 REV. 10/82