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APPLICATION FOR PERMIT �f �- � _` SA OAQUiN LOCAL HEALTH DISTRICT 16' 3 r, +�"' � '& . AZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 . 66 DATE ISSUED EXPIRES I YEAR FROM DATE ISSUED ) T r (Compl to in r�plicat ) ( �G/ t r la a ��n A �c z F, s T Zvi✓ ,�, a!�r�� Application is hereby made to the San Joaquip�Loca Health District fora permit t ons ruct and or ins all the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel,l�Ipum_p_ and the Rules and Regulations of the San Joaquin Local Health District. /0t- Job Address l ixtAiJNmi) aerj a) Det/k?r J/ar__ A16W-fs6eNJ? W-1Z Rb OW JC-1D VF_IQ �W —RI Owner's Name imam Contractor's Name C&WIOME /}Q/�[ZA(& License No. 1Uw Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-] DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK )VONA SEWER LINES � DISPOSAL FLD. AV" PROP. LINE FOUNDATION AGRICULTURE WELL l E OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial- U Open Bottom Manteca T 4 Dia. of Well Excavation L5woomestic/Private 2<Gravel Pack Tracy Dia. of Well Casing /Q - EJ Public Other Del ta Irri ation .-� � W Type of Casing ~� 9 Approx, Eastern Specifications Cathodic Protection Depth Depth of Grout Seal sy L-]Geophysical Type of Grout ML U Other - Surface Seal Installed by F Repair Work Done Q Type of Pump H.P. State Work Done �l Well Destruction U Well Diameter Sealing Material (top 50') _ I_ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl 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 living units: Number of bedrooms Lot size rti Character of soil to a depth of 3 feet: Water table depth I�} SEPTIC TANK EJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size `f! FILTER SED ED Distance to nearest: Well Foundation Property Line , SEEPAGE PITS ❑ Depth Size Numbed SUMPS El Distance to nearest: Well Foundation Property d DISPOSAL PONDS ID 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 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 applican us all or a • re uired inspections. Complete drawing on reverse side. " Signed X Title: Date: ' R DEPARTMEN USE ONLY/d Application Accepted'iby Area �!7 [] Stk 466-6781 Additional Comments; 0 -Lodi- 369-3621 Pit'or Grout Inspection by A&ArAtVJVJ1 t Date f Manteca 823-7104 Final Inspection byDate -�y Tracy 835-6385 Applicant -' Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE _. BASE `AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. INFO {J '' ¢r EH 13-24 REV. 10/82 10/82 500 14-26