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i r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH.OISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephoii.e (209) 466-6781 w DATE ISSUED _ — PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) E Replication 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 ;2a ,g- VYAIF .�'7- Subdivision Name .L07--d7=��Go2� Owner's Name A R/ Address / KE p L g6 one Contractor's Name C 121��,.ltJodD License No. Phone _-K S 3 9 7 1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U `� ^ ----^---PUMP-.INS-T-AL-tAT-I0N—d-----S-Y-ST-EM-RE PAIR-- l - '• OTHER Lf DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE rw FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE e .ted. -`TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia, of Well Excavation Domestic/ rivat'e � U P � � Grave] Pack � Tracy 44�];. Dia': of .Well Casing Public F-1Other E] Delta Irrigac 1 i Type of Casing 1 tion- � � APPro`z""°�-"''Eastern'""''"""`""'--'"';""""-' ' Specifications Cathodic Protection � Depth 5 P Geophysical i Depth of Grout Seal U Other 'I i Type of':Grout Surface Seal Installed by Repair Work Done Type of Pump H.P.. State Work Done . u. Wel] Destruction U Well Diameter Sealing Material (top 501) 9 a. Depth Filler Material (Below 50') ' � r TYPE OF SEPTIC WORK:] NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is ° available within 200 feet.) Installation will' serve: Residence ✓ Commercial Other Number of livingfunits: Number of bedrooms ^ Lot size 7 S XJ S Character of soal:Mto_a_depth_o.f 3 feet: L Water table depth SEPTIC TANK I ! Cj Type/Mfg. - �'t4-�I x a 0 Capacity No. Compartments i PKC. TREATMEtVT PLT. [] Type/Mfg � Capacity Method of Disposal (i1 SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION 1,cz, LEACHING LINE u` No. & Length of lines l— Lip / Total length/size �X y FILTER BED Distance to nearest: Well _IqFoundation Property. Line /S SEEPAGE PITS ) Depth r a, Size ,3� " Number J SUMPS AL1 Distance to nearest: Well JFoundation ,�Q ' Property Line Zr DISPOSAL PONDS ❑ 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 rul>es,rand regulations of the San Joaquin Local Health District. Home owner or licensed agent's syighature 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 workmans compensation laws of California." Contractor's hiring or sub-contracting signature certifies the-folhowing:."I certify that in the performance of the work for which this permit4is issued;-1 shall employ persons subject to workman's compensation laws of California." The applicant must ca h for al.I`required spections. Complete drawing on reverse side. Signed X Title-. @ Date: l 7- # # � O PARTMENT USfrDNLY Application Accepted by Area `g Stk 466-6781 Additional Comments: ' ! i E] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Finai Inspection by -' _ -' Date_1_Z�_p7 �} Tracy 835-6385 Applicant -Return all copies to: Environmental alth Permit/Services 1601 E. Hazelton Ayel, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFD _ CPT EH 13-24 10/82 500 ► 14-26