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f APPLICATION FOR PERMIT SAN JOAQJiN LOCAL HEALTH DISTRICT 1601 E. HA2ELTON AVE., STOCKTON, CA PERMIT NO. j :✓ Telephone (2.09) 466-6781 K DATE ISSUED •+y 1/93 + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) y 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 Distri t. Job Address_ VINE 5-r- ion Name Owner's Name 2>A W Al Address Z93 Phone 4Zrr- SII j Contractor's Name �`L��p) y�a�� License No., Phone Phone 44S1397J TYPE OF WELL/PUMP WORK: «NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ L. J -`PUMP-INSTALLATION -FI—SYSTEM`REPAIR "OTHER' U f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE L FDUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS CI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ff Industrial U Open Bottom M Manteca Dia. of Wel I [Excavation , ❑ Domestic/Private Gravel Pack Tracy Dia. of Wel lICasing Public ,❑Other ® Delta Type of Casing F ❑ Irrigation Approx. ❑ Eastern' Specifications • ' [ Cathodic Protection Depth Depth of Grout Seal _ `s +� Geophysical ❑Other - Type of Groutl i Surface Seal Installed by ° y Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ ,Well .D'meter Sealing Material (top 50') 5 ' DepthJ ' Filler Material (Below 50') ` TYPE OF SEPTIC,WI kNEW,INSTALLATION ❑ REPRIR/,4DDIT10N le(No septic tank or seepage pit permitted if public sewer is 'L, , f s "le — available within 200 feet.) Installation will serve:yy Residence r� Commercial Other Number'of living units:11/ %r Number of bedrooms Lot size _'7sc mss Character of soil to a depth of 3—feet:- C J-A y Water table depth SEPTIC TANK Type/MfgCapacity /Lg No. Compartments . V j PKG. TREATMENT PLT. Type/Mfg ,� Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line - --DESTRUCTION ❑ I _Azaac LEACHING LINE ❑ No. & LVt tlJraf ,lines Total length/size` C— d/f- FILTER BED stn ar`est: Well Foundation ;Property Line SEEPAGE PITS I DepthSize Number SUMPS Distance to nearest:1 Well `1 Foundation Property Line DISPOSAL PONDS I hereby certify that ] have ,prepared th slapplication andithat the work will be done in accordance with San Joaquin county d 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 certifies4the 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 must call for 1 required insp tions. Complete drawing on reverse side. Signed X i Title: [3r/- # F Date: i a i DEP MENT USEDNLY E Application Accepted by „ fi Area Stk 466-6781 Additional Comments:. e Lodi 369-3621 Pit or Grout Inspection by —6L9 Date LJ Manteca 823-7104 Final 'Inspection by '" "" 'Date " — ❑ Tracy 835-6385 Applicant - Return all copies to: Envi ental Health Permit/Services 1601 E. Hazelton Ave., P.O. .Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO , EH 13-24 REV. 10/82 - , 10/82 500 14-25