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r APPLICATION FOR PERNT7 SAN JOAQ1,1N LOCAL HcALTH DISTRICT A / 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. 7 9 Telephone (_0 ) 466-6781' 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 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 2 .5-Q+3 C_�C.C_ r/ Subdivision Name Owner's Name Address •7 JM,5r SU' C.' ( 70 h.2 Phone Contractor's Name LAPX IWGXI-� icense No. 'i 7„ W 4( Phone s TYPE OF WELL/PUMP WORK: NEW WELLELL REPLACEMENT DESTRUCTION 0 PUMP INSTALLATION VSYSTEY REPAIR OTHER U ` �- DISTANCE TO NEAREST: SEPTIC TANK lQ [g SEWER LINES DISPOSAL FLD. PROP. LINE 7 0 . i t- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS {n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS „I_ IrOeTf r i a 1 a Ope ottom Q Manteca Dia, of Well Excavation Domestic/Private ravel Pack [f Tracy Dia. of Well Casing t :1 Public U ether Delta Type of Casing �Xt L2,,, S t L; EL V,Irrigation Approx. Eastern ❑ Cathodic Protection Depth Specifications _ Depth of Grout Seal F-IGeophysical Type of Grout 9 SA—C) /q/ Y Other '?? Surface Seal Installed by C CA ) Repair Work Done Q Type of Pump U rJ H.P. I1// 2_ State Work Done Well Destruction U Well Diameter " Sealing Material (top 501) _ Depth '�Fil-ler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A6DITION J (No -septic tank or seepage pit permitted if public sewer is '�� available within 200 feet.) Installation will serve: Residence Commercial .,, _Number of living units: Number of bedroom§' Character.of soil to a depth of 3 feet: Other Lot size Water table depth SEPTIC TANK'; E:] Type/Mfg s. b Capacity No, Compartments PKG, TREATMENT PLT. [1];- ! Type/Mfg Capacity -Method -of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION Q LEACHING LINE ❑ No. & Length' of lines FILTER BED Distance to nearest: WelI Total length/size. Foundatior' Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line f ti DISPOSAL PONDS i- I hereby'certi,fy that I have prepared this application and that the work will be done in accordance with San Joaqui^county ordinances; -state laws, and rules and regulations'of the San Joaquin Local Health'District.- Home owner or licensed agent's signature certifies the ;fo"ftowing:'"I certify that in the performance of the work for -which this-- - — permit is issued, I shall not employ any person in suc'li manner': as to become subject to workman �, compensation laws of California." C6ntractor's hiring or su cti'n " signature certifies fhe°follbwing: "I certify'that in the performance of the work -for -which._ -__i this permit i 15s ed, I all_e y rsons. subject.fo workman's compensation laws of California's The applic t us ca 1 F 1 q 'r ns cions. Complet d ing,on�r er i'de.' " ...,Signed-X� _ _ .TJ11e:4 ��`y FOP,DEP . E _ONLY- Application Accepted by sea_ 5tk 46b- 8 Additional Comments: F' Lodi 369- 621 Pit or Grout Inspection Date Manteca 623-7104 Final Inspection by ti Date ——fz'kA,L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f ` FEE BASE AMOUNT DUE AMOUNT REMITTED t P:�RE=CEJ�V.EDY DATE PERMIT NO. INFO � EH 13-24 REV. 10182 i, + 10/82 500 14-26 e