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ry(f 1 APPLICATION FCR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 - 1 DATE ISSUED 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 it 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 j�3100 E, I/icTVR LoI�_f_ Subdivision Name Owner's Name L!-V..�s� 7 , Address Phone 27-S ' C99-:5 Contractor's Name 61)3:50&1 y1 ::P 14L No. -37 o�Z_ Phone 2��-33_77 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑� OTHER Q DISTANCE TO NEAREST: SEPTIC TANK OO fi SEWER LINES 'gQW DISPOSAL FLD. _. PROP. LINE _ Q FOUNDATION fi AGRICULTURE WELL -- OTHER 14LLL --PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IndustrialOpen Bottom ❑ Manteca Dia. of Well Excavation j Lf Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing /� /^ I �� Irrigation ��Approx. ❑ Eastern ❑ Cathodic Protection=, Depth Specifications 17 I Depth of Grout Seal ❑Geophysical Type of Grout f ❑Other r Surface Seal Installed by Repai'r Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') _ x Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑1 REPAIR/ADDITION U (No septic tank or seepage pit 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 of 3 feet: Water table depth 1 -'-"-SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal- 1 k SEWAGE SYSTEM 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 v , SEEPAGE PITS Depth Size Number ""6' ��" SUMPS -❑ Distafrce to-nearest:'*'Well m- 'Foundation - Property'Line.r DISPOSAL PONDS ❑ 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 District. 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 employ any person in such manner as to become subject to workman t 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 applicanA must call or 11 equ" ed inspections. Complete drawing on reverse side. Signed X Title: Date: DEPART NT USE ONLY g- Application Accepted by' -- O� (Area �,___ ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by A Date LJ Manteca 823-7104 - + Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental He th Permit/Se>yces 601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �^ DATE p PERMIT NO, INFO 1W s?��.5 b� �D EH 13-24 REV. 10/82 Fe-� C--*r- 10/82 500 j 14-26 7 r