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APPLICATION F0 PER'';! SAN JOAQbiN LOCAL n_xLTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone{209) 466-6781 DATE ISSUED \/ PERMIT EXPIRES i 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 AddressZ , S , SIAI e'1-A /Imo, Subdivision Name Owner's Name 8JLi- ZAil,444-fes Address r SALPIe5 Phone Contractor's Name �(.d Kr,> a License No. Phone 4r- 27-1 G TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L❑ OTHER ❑ { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS71 E a [JCl Industrial ❑ Open Bottom [J Manteca Dia. of Well -Excavation �. LYj Domestic0rivate ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing ❑j Irrigation Approx, ❑ Eastern - Depth Specifications Cathodic Protection - - --�=c Depth of Grout Seal , - _ ❑Geophysical Type of Grout U Other Surface-Seal Installed by------.--�—� E Repair Work Done ❑ Type of Pump H.P. State Work Done ) Well Destruction.0 Well Diameter Sealing Material (top+ 50') _ Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION E (No 'septic tank or seepage pit permitted if public sewer is n� / y available within 200 feet.) �J y Installation will serve: Residence S Commercial Other c a j- w ai-e- - _Se4-v Number of living units: Number of bedrooms 7� Lot size - Character of soil to a depth of 3 feet; AV _ Water table depth SEPTIC TANK Ej *Vf fge r ' Capacity No. Compartments PKG..TRtATMENT PLT. [ 9 Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: , Well Foundation,__ Property-Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines / _ Total length/size FILTER BED ❑ Distance to nearest:,. Well Foundation 1(0Property Line a i SEEPAGE PITS Depth y� Size '� f� Number SUMPS Distance to nearest: Well Foundation _ -:S Q Property Line 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent`s signature certifies the fallowing: "I certify that in the performance of the work for which this permit i5 issued, I shall not employ any person in such manner as to become subject to workmant 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 applicant must 11 fo all requir nspections. Complete drawing on revers e�s•ide. Signed X Title: Date: 4-3 FOR DEPAR Y Application Accepted by Area ❑ Stk 466-6781 Additional Comment � ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final-inspection by Date y L7 Tracy 835-6385 Applicant -- Return all copies to. nviYoninental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3 �Q J (� 10/82 500 EH 13-24 REV, 10/82 + 14-26