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MICE 17 APPLICATION FOR PERyiT SEP 1,9 SAN JOAQUiLN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT N0. SATelephone_(209) 466-6781 �� DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fq (Complete in Triplicate) Application is hereby made totheSan 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 Joaq in Local Health District. a, Job Address ZUCIL 1Z lSubdivision Name Owner's Name 'sc LD 'fir•, e /2 dd ss Phone �..� Contractor's Name O—) License No.pL��gl1/ Q Phone 2 ZU TYPE OF WELL/PUMP WORK: NEWiWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Od PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER �❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �tQ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS lv Industrial �l ❑ OpenlBotto -.0 Manteca Dia. of Well Excavation Domestic/Private Gra-vel.=Pack- Q Tracy Dia. of Well Casing _ ❑ Public CI Other ❑ Delta 71 Irrigation -ApproX':"�©Eastern"" YT Type of Casing i ••-�otection Depth-"--' Specifications -❑Cafhodic Pr Geophysical Depth.of Greut Seal ❑ *�� I - Z. Other �- -tyP�bf Grout, �y Surface Seal Installe by Repair Work DoneR Type of Pump H.P. J.S State Work Done lRekZAq4- p Well Destruction ❑ Well Diameter` Sealing Material (top 501) Depth Filler Material (Below 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONj J (No septic tank or seepage'rpit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other ; Number of living units: ,, '"~`Number of bedrooms Lot size Character of soil to a depth bf,3 feet'' �r ��' : ' f ', J 'Water table depth SEPTIC TANK__[-] Type/Mfg Capacity No. Compartments �- PKG. TREATMENT PLT. ❑ Type/Mfgf - Capacity Method of Disposal SEWAGE SYSTEM II�� Distancetone est: Well/ Foundation Property Line �5 DESTRUCTION -41 LEACHING l LEACHING LINE ❑ No. & Length of lines i Total"-qengt-h/size , FILTER BED DistanceJonearest: Well Foundation Property Line �r SEEPAGE PITS �FDepiYi size Number } SUMPS z❑ `3bi',tanca-to-:near. st: Well Foundation Prop;erty Line 1 r DISPOSAL PONDS ID I,-. � .�-�-•�� ;,�,,._�•�,_--^-- ��i 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 Oilstric"t`• Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for, which this permit is issued, I shall not emp,lgy.any.person in such manner as to become subject to work'man� compensation laws of California." Contractor's hiring or sub-contrac}tfng-;signature. certifies the following: "I Zcertify--that in the performance of the 'work for which ' 4 this permit is issued, I shallploy persons subject to workman's.compensat ion laws of Ca lifornia," l The applica st all o a required inspections. Complete Yainglon reverse std . Signed X + • Title; ; { Date: / 151 !AMENT I ONLY Application Accepted b Area Stk 466-6781 Additional Comments: : ❑ Lodi 369-3621 Pit or Grout Inspection by/# Date ' �4 Manteca 823-7104 Final Inspection by ❑ Tracy 835-6385 Applicant - Return all copies to. n ironmental h 'Permit/Services 16 1 E. Hazeltor Ave., P.O. Box 2009, Stk., CA 95201 4_ FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 s F 10/82 500 14-26 (p