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I� APPLICATION FOR PERMIT SAN JOAQUIN LOCA! H A.LTH uISTRICT $ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. U �S� i� Telephone (209) 466-6781 # I, 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 Sar 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 O -y" Subdivision Name _ n,iPe5 iAA',C",S Owner's Name T, 1), .5• : Address "-� � Q Phone Contractor's Name . i, License No. ' ' Phone h F ' TYPE OF WELL/PUMP WORK: ii NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST:`SEPTIC!TANK SEWER LINES DISPOSAL FLO. PROP. LINE ? I ? FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 11 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSEl . F Industrial [f Open Bottom ❑ Manteca Dia. of Well Excavation i ❑ Domestic/Private ❑Gravel Pack ❑,Tracy Dia, of Well Casing ❑ Public Other Delta G❑ ❑ Type of Casing Li Irrigation CKs Approx. ❑ Eas ern i Specifications 1 ❑Cathodic Protection Depth } ' Depth of Grout Seal + } 1-1Geophysical �, Type of Grout E ❑Other I! Surface Seal Installed by rl j Repair Work Done Type of Pump H.P. State Work Done I i Well Destruction ❑ Well Diameter Sealing Material(top, 50') 1 Oepthl�' Fill (Belo 50') Jar Material ' I . OF SEPTIC-WORK -N�41--,4STP-LLA-T,I.OL Q_REPA[RJ,;ADDJTIDW��)-,.(No..septic _tank or seepage pit.permi�ted if public sewer is \ �( 1 - I- t: °- - 'W v71 thin�200rfeei� ) k Installation will serve:l1 Residence Commercial:" Otlier ' i v ; Number of living units: p Number of bedroorgs L Lot size y ' ! i Watdr table dep&,,' Character of soil_to_a-depth of 3 feet: �¢-06ME �W SEPTIC TANK „Sype/Mfg a ,-, Capacity 6� No Compartments PKG'. TREATMENT PLT. :+ Type/Afg Capacity ;Method of Disposal I SEWAGE SYSTEM Distar`ace to nearest: Wel li fEoun'dation Property, Line i DESTRUCTION LEACHING LINE -No: &a Length of lines r � , Total length/size FILTER BED ❑ Distance to nearest: -`'A Fourdation Property Line j SEEPAGE PITS EDDepth �Size� ' , Number qr h SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONS I Hereby certify that 1 have prepared .this application andhthat-the work wil3, a done in accordance with San Joaquin county f ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dist-rift., 'r Home owner cr;liicensed agent's Signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall Inot employ any person in such manne�as.to_,become subject to workman compensation laws of California.” Contractor's hiring or sub-con ttacting'signature certifies the fo -fowrng:-"I certify that in't6e performance of the work for which this permit is issued, I shall gmplcy persons subject-to workman's compensation laws of California." The applicant}tpust call for all`'required inspections. CompleteTdrawing on"reverse side. Signed ( Title: ; Date: MENT USE ONLY Application Accepted by Area r ❑ Stk X466-6781 I [] Lodi 3 369-3621 } Additional Comments: 1 4 l Y Pit or Grout Inspection by Date Manteca'823Y7-i94 ` Final Inspection by Date € L7 Tracy 835-6385 Applicant - Return all copies to: Environmente ealth Permit/Services 1601 EJ Hazelton Ave.; F.D. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED R . RECEIVED'BYf 'DATE ' PERMIT N0. INFO _ 10 I" 13-24 REV. IO/82 �I� I Bt 14-26