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F ' APPLICATION FOR PERMIT SAN �OAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. N. �s Telephone (209) 466-6781DATE 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 � `!� T*6-7- Subdivision Name / I Owner's Name ��G ° j7AZ �S —Address / � � j1 -T 49 Phone Contractor's Name License No. 15: ;Sl J , Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION )] SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTICr,TANK SEWER LINES DISPOSAL FLD. PROP. LINE ..,, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE �` I� TYPE OF WELL —EROBLEM AREA CONSTRUCTION SPECIFICATIONS y 1J Industrial UrOpen Bottom F Manteca Dia, of Well Excavation f U Domestic/Private ° ©.Gravel Pack, [I Tracy Dia. of Well Casing T Public # Other 0 Delta J Type of Casing Ljirrigation # .� Approx. Eastern 8 s Specifications ❑ Cathodic Protection ) -"} Depth I " # 0th of Gr`oM"Seal s Geophysical v *. _ I Type of Grout Lj Qt�h�er ,� Surface Seal Installed by Repair Work Done D Type, of'Pump H.P. State Work Done Wel 11 Destruction [J -�WelI? Diameter .Sealing Material (top 50') i _Depth�p 'Fil her Material (Below 50') ( v 1 TYPE OF SEPTIC WORK. NEW INSTALLATION [!'REPAIR%ADDITION (No septic tank or seepage pit permitted if public sewer' is 6Z ' a FSP f I available within 200 feet.)'Ya Installation wl]+,serve esi'dence. Commercial _ Other t i Number 'of 1iving�,un.its:j= fVumber.of bedrooms Lot size p7 I ! Water table de th 1 Character of. so i-1 to a depth of 3 feet: �� _ P � � SEPTIC TNK + Type/Mfg; Capacity D No, Compartments PKG. TREATMENT PLT. Type/Mfg ? Capacity Method of Disposal , 4 SEWAGE SYSTEM Dist nce?to nearest: H Wefl `- Foundation Property Line i DESTRUCTION I� `f LEACHING LINE No.,& Length of lines Y% * total length/,sizeTf V 3ari FILTER BED Distandeyto nearest WeII Foundation . V - . Property Line ` SEEPAGE PITS F-1 Depth - Size Number SUMPS U ,Distance to nearest: Well Foundation Property LineM.,T � DI POSAL PONDS �I I "" t ��i r i ;II 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. I 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 shallinot employ any person in such manner as to !become subject to workmans compensation laws of California." Cohtractor'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 cohpersation laws of California." The applicant must call " quire i spections. Complete drawing on reverse side. Signed X s °�i Title: Date: y F DEPARTMENT-USE-ON-Y-�»«.-r-1 x I Application Accepted by 0 Area Stk 466-6781 I ' Additional Comments. T— 0 Lodi 369-3621 ; Pit or Grout Inspection by Date Manteca 823-7104 � Final Inspection by,1 A N.A Date L Tracy 835-6385 Applicant - Return all copies to:—Environmernt ealth Permit/'Services 1601 E. Hazelton Ave., P.O. Box 2009,. Stk_, CA 95201 FEE BASE AMOUNT DUE , AMOUNT REMITTED RECEIVED BY DATES PERMIT N0. I .41.41 V\'y 4"41 10/B2 560 .4 -�-•EHw13-24�.,.REV-.10/82. - 14-26 19