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J APPLICATION FOR PERMIT SAN JOAQU;" LOCAL HEALTH DISTRICT 1601 E. HA7ELTON 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 Address / / G Subdivision Name 3Garf �Z 3t� Owner's Name �} .( A dress �/2 O IAId A C'oX 9� ate; _ phone Contractor's Name O-64 License No. aZ 1 (0 Phone TYPE OF WELL/PUMP WORK: NEWWELLWELL REPLACEMENT DESTRUCTION 3' PUMP INSTALLATION SYSTEM REPAIR L OTHER U DISTANCE TO NEAREST: SEPTIC TANK, I O © -f* SEWER LINES DISPOSAL PLO. PROP, LINE /S FOUNDATION �I'L '�- AGRICULTURE WELL / � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Af L Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Domestic/Private ` Gray el PackTracy— „•' ' Dia. of Well Casing �o Public Other Delta Type of Casing G°.�ASS 146 O 11 V V Irrigation Approx. Eastern Specifications Cathodic Protectidrr ' Depth �i _Iy- pep-of Grout Seal .50 +� Geophysical k Type of Grout E -riR At/T \i LOther •` `, ,,: Surface Seal Installed by'044iQ/it+(/AA6 -^ Repair Work Done L Type of Pump VfUSB H.P. t 1�.�k- -i 'tate Work Done _`4/ - Well Destruction U Well Diameter Sealing Material�(top{50') Depth.. -� . Filler_,Materia] (Below 50') �'k 1 TYPE OF SEPTIC`WORK: NEW INSTALLATION U REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is ;W available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: N`unber of-bedroo as' -'"" "'k Lot size_ Character o-soil to a depth^of 3 feet: Water table depth SEPTIC TANK e �j—Typ JMfg Capacity No. Compartments PKG. TREATMENT-PLT. ❑ Type/Mfg * Capacity ' � L Method of Disposal «: SEWAGE SYSTEM V111T _ Distance to'nearest: Well Foundation v`4Property Line DESTRUCTION ❑ - '•^ LEACHING LINE _ L No. & Len.gth of�lines Total length/size 1 FILTER BED Distance to nearest: Well Foundation., --_. Property Line '• SEEPAGE PITS Depth # Size i Number SUMPS Distance•to-nearest: Wel']— -Foundation "'y"'rProoperty-Cine DISPOSAL PONDS 1 i... ♦ter . 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 regulation§'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." E 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 applic # calall required inspect ons.` Complete-dra ng on reverse side. �Sign`ed4` Title: �f c� T LI @ Date: //" �8 �ORDEPA�RTM�11 E ONLYApplication Accept d 6y Area Stk 466-6781 �.,-.-. ! r Additional Comments: ��" /� Lodi 369-3621 c� Pit or Grout Inspection"by - � Date \ � Manteca 823-7104 Nle, Jj Final"Inspection by l i � 4' * - Date /� L Tracy ,835,6385 p` Applicant � pp - Return all copies td.. Environmental He lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT.REMITTED RECEIVED BY DATE p. PERMIT NO. INFO ` t. 4 - a.. .- _7 IJD _ 77 IJ�•G� f 41DA2 500 1 EH 13-24 REV. 10/82F 14-26