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APPLICATION FOR PERMIT SAN JOAQU-LN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 GATE ISSUED �-�7-5LI PERMIT EXPIRE$ 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 Sar 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 85'd/ 3vgAr fly TyeSrc . Subdivision Name Owner's Name 5o1AY S yTenrs Address JV 20 Sr&,q Z4 Ra/ i9c Phone Contractor's Name y /sp '1f Sp License No. YW e5rl Phonesr93-z/.t TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION (] SYSTEM REPAIR 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 SPECIFICATIONS 10 Industrial U Open Bottom F] Manteca Dia. of Well Excavation U Domestic/Private F-1 Gravel Pack F�Tracy Dia. of Well Casing 0 Public f-1 Other Delta Type of Casing 71 Irrigation Approx. Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal a Geophysical Type of Grout J U Other Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Dane Well Destruction L_I Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') Y TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) .� Installation will serve: Residence X Commercial Other Number of living units: / Number of bedrooms 3 Lot size ;Oe,*--res Character of soil to a depth of 3 feet: � Water table depth 8' SEPTIC TANK [Yj Type/Mfg �0 ce Gg�sT Capacity.T-/ n b No. Compartments y PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation /® Property Line 1-5V'/j/� DESTRUCTION ❑ 4` LEACHING LINE No. & Length of lines - Add'X f/ Total length/size ,x pe' FILTER BED Distance to nearest: Well Foundation /e' Property Line s� SEEPAGE PITS Cj Depth Size Number . SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i 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 applicant must all for all required inspections. Complete drawing on reverse side. Signed X Title: Date: .7-3/',sfY Replication Accepted by F DEPARThyF�IT�1S Ri�tX/ Area 67 Stk 466-6781 Additional Comments: 7"4Hah 'CfD `.� Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 3 LTracy 835-6385 Applicant - Return all copies to: nvirvnmentrmit/Services 1601 Hazelton Ave., P.O. Bax 2009, St k., CA 95201 FEEBASE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 14-26 JJ