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u APPLICATION FOR PERMIT } :I SAN JOAQUIN LOCAL,HEALTH'DISTRICT Spi � . 1601.1]. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED kr 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. (�} Job Address .2µ4.20 ,,.. Subdivision Name LT" f Owner's Name Address , ��15-' a. s.. Phone i Contractor's Name /ar¢Q�jS,� (�rj License No, Phone �y'�p7 Y TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ,f. OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. r" PROP. LINE . -- FOUNDATION -! AGRICULTURE-WELL_ + OTHER WELL PITS' /SUMPS ' INTENDED USE tYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ii f t Industrial 'I- S Jill U Open Bottom Manteca Dia. of Well Excavation i ? U Domestic/Private d! ❑Gravel Pack Tracy Dia. of Well Casing Public F Other El Del to ! k4 , F. 9 " Type of Casing d ❑ Irrigation Approxi []Eastern { Specifications i € Cathodic Protection ' Depth " Depth of Grout Seal " ❑Geophysical ❑Other +111i� �;, Type of Grout Surface.5eal Installed by Repair Work Done ❑ Type "of Pump H.P.' a^'— State Work Done ' Well Destruction [f Wel Ill Diameter Sealing Material (top 50') ► Depth Filler Material (Below 50') §' TYPE OF SEPTIC WORK: NEW' INSTALLATIONV REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted.if public sewer is 0 available within 200 feet.) Installation will serve: Residence V commercial _ Other Number of living units.'j_ Number of bedrooms _ Lot size - �jCJa cS Character-of'soil to a .depth of 3 feet: _�}�Q E Water table depth 134) SEPTIC TANK ;Type/Mfg (r/�/J�, � 5 '' Capacity /&690 No. Compartments PKG. TREATMENT PLT. ��Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ! Distance to nearest: Well /zjjp Foundation ^�� Property Line /062 s DESTRUCTION ❑ ? \` Y LEACHING LINE pNo. & Length of lines Total length/size Z FILTER BED is Distance to nearest: Well _/4eiR2 Foundation �,�� Property Line /V d!7 4- SEEPAGE PIT$ ii Depth �� Size 33 _ Number �3 e SUMPS L� ' Distance to nearest: Well 'f 0 Founda'tior 71�- Property Line DISPOSAL PONDS CI =' I hereby certify that 1 }ave 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 li ensed agent's signature certifies the following:_ "I certify that in the performance of the work for which this permit is issu , I shall, not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's ing or sub-contracting signatur, certifies the following: "I certify that in the performance of the work for which I this perm t "s ssued, Ishall employ _ sons bject to workman's compensation laws of California." 4 The app nt it for 1 re d ctComp ete n verse si ! Signed Title: Date: j FD PARTME T USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: �odi 369-3621 ` Pit or Grout Inspection by Date ❑ Manteca 823-7104 Y Final Inspection 6y Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environments Health Permit/Services 1601 E. Hazeltor Ave., P.O. Box 2009! Stk., CA 95201 FEE BASE '•AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM INFO IT N0. k `' g3. I ij I0/82 500 EH 13-24 REV. 10/82 ;J 14-26 i�