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t APPLICATION FOR PERMIT SRN JCAQUILN LOCA'_ HEALTH DiSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 PERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED DATE ISSUED '3o977 (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 appycation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump and the Rules and R tions of the San Joaquin Local Health District, Job Address 4oT*i. &E6 CT. re, yV40bdi vi slon Name Owner's Name R47 AA79M1r.0Nf) Address ,30 ZOO So. !`6i,-ery 33 75,.4 zV Phone Contractor's Name /fyT/ie/Yr Se N' License No. Yyy- crq/ Phone TYPE OF WELL/PUMP WORX: NEW WELL WELL REPLACEMENT. ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR U OTHER U 4 oe ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS QQ Industrial U Open Bottom Manteca Dia, of Well Excavation L} Domestic/Private Gravel Pack F-1 Tracy Dia. of Well Casing '1 Public Ej Other. ri ❑ Delta Type of Casing Li Irrigation ' --Approx. Eastern ` Depth. Specifications E] Cathodic Protection , Depth of Grout Seal Geophysical � Type of Grout Lf Other I Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material {top 501 _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION R1 REPAIR/ADDITION ❑ (No septic-tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence V Commercial _ Other Number of living units: J Number of bedrooms -7 Lot size /x Acres f Character of soil to a depth of 3 feet: G '9X A 0'yM Water table depth �• SEPTIC TANK U Type/Mfg Be CA r9'" ctwy Capacity /;too No. Compartments � PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line -� DESTRUCTION C] ` LEACHING LINE No. & Length of lines 3 - 90' Total length/size FILTER BED Distance to nearest: Well /OD' Foundation /0' Property Line 4 X" �' t i SEEPAGE PITS Depth Size Number i SUMPS J Distance to nearest: Well Foundation Property Line DISPOSrAL PONDS �} I her certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I 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 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, st call for all required inspections. Complete drawing on reverse side. Signed X d'.l! y/� Title: Date: FO EPARTMENT USE ONLY Application Accepted by Area F 7 ❑ 5tk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 t Final Inspection by L Date � Tracy 835-6385 Applicant - Return all copies to: Environmental th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F' FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 14-26