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APPrICATICN FOR PERMIT SAN JCAQUiN LOCAL HEALTH DISTRICT q z 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. U✓ " (Q Telephone (209) 466-6781 PATE ISSUED PERMIT EXPIRES liYEAR FROM DATE ISSUED (Complete-in Triplicate) - Application is hereby made-to the San Joaquin Local Health District fora 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 A I A4 16re Y int/ W, ,v Subdivision Name M Owner's Name Address A1.46y �l�u,br��i�J,UbrY Phone, C?2r- Contractor's Name Ej9�/r SAiY ` License No.: Phone TYPE OF WELL/PUMP WORK: w NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC-TANK s SEWER LINES ' ' " DISPOSALF Cb. POP, INE FOUNDATION AGRICULTURE WELL ` OTHER WELL PITS/SUMPS �J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial JU Open Bottom Manteca ! Dia. of Well Excavation " f L_I Domestic/Private i❑ Gravel Pack Tracy Dia, of Well Casing ,J s f Public Other Delta r `f Type of Casing =_ V Irrigation Approx. E] Eastern -�- -- - �� Cathodic Protection Depth Specifications i Depth'of Grout Seal 1-1 Geophysical s ;/ ,) Type of Grout r U Other '- Surface Seal Inst11 alled by Repair Work Done Type of Pump N.P. State Work Done Well Destruction LJ Well Diameter ^tr'Sealing Materia l- top 50') � Depth Filler Material (Below 50') f TYPE;OF.SEPTIC WORK: NEW INSTALLATION ❑ �'REPRI`R%,4DD;IfiION` j" (No"septic tank or seepage pit permitted if public sewer is - - - "' " � available within 200 feet.) Installation will server Residence Commercial _ Other i '' 'Number'of'lwing units: 7 Number of bedrooms Lot size lcyox Character of soil to a depth of 3 feet: 5i#'4 Water table depth SEPTIC TANK Type/Mfg c e"i r7, CoiYG Capacity 1.100 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ff Distance to'nearest: Well Foundation Property Line DESTRUCTION - LEACHING LINE No. &,Length of lines Total length/size FILTER BED Distance to nearest: Well !��' Foundation Property Line SEEPAGE PITS [j 'Depth i Size ' * Number SUMPS ' ',Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �� - r 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 cr' licensed agent's signature certifies the following: "I certify that in the performance of the work for which thissz4;` permit is issued, I shall -not employ,any person in such manner as to become subject to workmanS 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 applicant i st call for all required inspections. Complete-drawing on reverse side. Signed X s Title: Date: f ' FOR DEPARTMENT USE'ONLY Application Accepted by 1 L Area Stk 466-67B1� . Additional Comments. oLodi 369-3621 Pit or Grout Inspection .by r F Da 0 �'Manteca 823-7104 Final Inspection by:' y' � "^; i�Da,ee-w-0-k o� ❑ Tracy 835-6385 1bDi E. Hazelton Ave., P 0. Box 2009 Stk., CA 95201 � _ �n it nm en Health Permit/Services li nt Return all co copies E v a ' Applicant p FEE E AMT REMITTED RECEIVED BY . DATE PERMIT NO. INFO BASE AMOUNT DUAMOUNT. rI q13 '33- 1 � EH 13-24 REV. 10/82 T 10/82 500 14-26 _. 1 �