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k l APPLICATION FOR PERMIT ' SAN JOAQUIN,LOCAL HEALTH-DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA. PERMIT N0. Telephone (209) 466-6781 I 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, E' and the Rules and Regulations of the San Joaquin Local Health District, t Job Address_ � 1 /QLjlq�'�,_, dfil� STS Subdivision Name Owner's NameAddress Phone _ ?3'j Contractor's Name ' cense No. Z Phone ' E _ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP I�=' SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES �� 'f` DISPOSAL FLO. -- PROP. LINE 1111 FOUNDATION f AGRICULTURE.WELL OTHER WELL �3Oy PITS/SUMPS INTENDED USE t TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS17 , Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation " i �- -�Domesvl --tic/Priate- [Gravel;Pack=��:QTracY".�-��. a:-zof-Wei]=Casa ng�:L_.._..� -,�.--�. _; _� .� �Y. ❑ Public ❑ Other ❑ Delta - W -" frri ation Type of Casing j*✓yC ��A$.S `�� i U 9 / Approx. E] Eastern Depth Specifications Cathodic Protection Depth of Grout Seal j ❑Geophysical �CL`?r- 1 ❑Other Type of Grout C/J�L�'Ap��r � s _ _ �'"�� Surface Seal Installed by i Re air Work Done T e of Pum H.P. P ❑ YP P - r State Wark Done Well Destruction ❑ Well Diameter Sealing Material (top 501) 1 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK:µNEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is Coavailable within 200 feet.); Installation will serve: Residence mmercial Other - Number of living units: Number of bedrooms Lot size ` Character of soil to a depth of 31feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. Type/Mfg ! ? ❑ Capacity Method of Disposal 1 SEWAGE SYSTEMDistance to nearest: Well Foundation Property Li DESTRUCTION ❑ operLine 1 k LEACHING LINE ' '❑' No.-& Length of'lines Total length/size 1 , FILTER BED] ❑ Distance to nearest: Well }"' Foundation _ ., r Property Line SEEPAGE PITS ❑ Depth Size '. Number a SUMPS t ❑ Distance to nearest:. Welles F.—Foundation~ Property Line y Y DISPOSAL PONDS ❑-.'--_, I I hereby certify thatzl have prepared this application and that the work will be done iri accordance with San Joaquin county ordinances, state`,awsj 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 permlt,as i_ssued,�Irshal.l 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, T;shall employ persons subject tomworkman's compensation laws of California." The applicant ust c 1.1'f all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DUARTME14T US ON Y I Application Accepted by 3 �O 8 Area 5tk 466-6781 3 Additional Comments: RLMa di369-3621Pit&or 6�routkInspection by Date - nteca 823-7104 �. . Final InpecFion byDate �.R- ❑ Tracy 835-6385 Applicant t Return all copies to: " E ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FFEE vBASE• ~^~AMOUNT-^DUE—�~-• ^�AMOUNT-,REMITTED•-� ^^•4iRECEIVED BY"�""~"•'�bATE""'-'-^" '—"PERMIT'N0."" EH 13y24 REV. 10/82 10/82 500 14-26