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'u APPLICATION FOR PERMIT SAN JOAQUi"; LOCAL HEALTH:DiSTRICT p+ / L:1 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. O 3 7 r Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED r (Complete in Triplicate) `Application is hereby made to the'San Joaquin Lccal-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 RegUldtionj of the San Joa ui.nLocai Healh.,District. Jab Address 11 Lidivision Name Owner's Name Address -14W 0. Z one Contractor's N ( cense No., � �� IJ Phone ,A(93 '- `F 'TYPEOF WELL/PUMP WORK: . NE4! WELL' WELL REPLACEMENT DESTRUCTION ` PUMP INSTALLATION SYSTEM REPAIR 'OTHER 'U (DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINE _ DISPOSAL FL D. PROP. LINE �1/1 1 FOUNDATION TM AGRICULTURE WELL OTHER WELL PITS/SUMPS ,I 17 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s 4 4 Industrial F-1 Open Bottom Manteca Dia. of Well Excavation T ❑ Domestic/Private F71 Gra_v_ei ck Tracy Dia. of Well Casing ❑ Public F-1 Other Delta Type of Casing F, Irrigation Approx. ❑ Eastern Specifications � Cathodic Protection `, Qepth � Sp ( # ., 4. Depth of Grout Seal Geophysical„ Type of Grout .❑Other .. Surface Seal Installed by Repair Work Done ❑ Type of Pump -^ H.P. State Work Done Well Destruction ❑ ,Well Di'ame/tgr,i �` Sealing Material (top 50') DepthF Ff Filler Material (Below 50') ~ TYPE OF SEPTIC WORK:-NEW'INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ✓ avaiT-able•within 200 feet.) Installation wil'1 'serve;' Residence ±Ir Commercial Other `' F Number of living uunits: Number of bedrooms � Lot size Character of soil to a depth of 3 feet: Water table depth ,SEPTIC TANK Type/Mfg; Capacity _ No. Compartments ~ PKG. TREATMENT PLT. ❑ Type/Mfg ; s Capacity _ Method of`Disposa} SEWAGE SYSTEM Distance fo nearest: Well f� ^f• Foundation f� Property Line �_ DESTRUCTION C] —S— DESTRUCTION _+ i LEACHING LINE No. & Length. of lines l Total length/size Q y "FILTER BEDDistance;,.tc,"nearest: Well gra +- Foundation �Qf Property Line SEEPAGE PITS EJ Depth T«yr Size �(a I al _ Number _ " SUMPS ��Distanc� to 'hearest: Well�`�j L+ Foundation -l_ Property Line y� "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, a,nd -rules`and regulations of the San Joaquin Local Health District. Home owner or licensed ag"t'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 einploy persons subject to warkman's compensation laws of California." 'The applicant. ..call.-For. -1-- quired,Atspec6ons. Complete drawing on'revprse_side. 1;P� i.Signed X ;.Title: 1L! Date .%�• { l 20R�QEPARTMENT USE ONLYJ _ � Appl icat Acce-pted by Area. a 0 `Stk 3.4b6-6781 Additional Comments: + - _ Lodi;- x369 3621 m Pit or Grout Inspection by Date - L Manteca823-7,104 Final Inspection by ate ❑ Tracy 835-6385 �.. �..P ,,.Applicant - Return all copi. s to: . Environmenta Health-.Permit%Ser_v ces 36D1 E. '-Alton Ave;, P-0. Box 2009, Stk., CR 95201 _.,-FEE_ BASE_ _ _.AMOUNT, DUE14 „-,AMOUNT-REMITTED RECEIVED BY DATE -3 PERMIT hl0. INFO �.. - ...PE :T N EH 13-24 REV. 10/82 10/82 500 14-26