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Ap /LYlAPPLICATION FOR PERMIT y7 it -41 7y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,t the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This:appiicatiohis made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reg lations of-the San Joaquin Local Health District. Job Address-10 1 o*b Subdivision Name Owner's Name i o V4 �, Address �4 � D �O� Phone Contractor's Name CLM lVAfil& License No. 71 Chis __ Phone iLr Ne CC— TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ W PUMP INSTALLATION SYSTEM REPAIR OTHER C3 - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS !' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing- Public _ D11 to - --- Type of Casing u Irrigation Approx. Eastern Cathodic Protection Depth Specifications. Geophysical Depth of Grout Seal; }� U Other Type of Grout _ �I Surface Seal.Installed by G O Repair Work Done [:] Type of Pump u? H.P. I State rWo?+,Done I �-Q L- — 4' Well Destruction U Well Diameter Sealing Material (top 54') -� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION L_1 (No septic tank or seepage pit permitted if public sewer is 4. F available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ype/Mfg_ " _w ` ' Capacity w No. Compartments PKG. TREATMkNT PLT. on Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No.'& Length of lines Total length/size -' FILTER BED Q Di§tA ce to nearest: Well Foundation Property Line SEEPAGE PITS rP-_.=Depth Size Number �. SUMPS u Distance to nearest: Well Foundation 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 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'A hiring or ub-contra ing signature certifies the following: "I certify that 'in the performance of the work for which this permi s issued shall em y per ns subject to workman's compensation laws of California." The applica must cal al r q ired spections. Complete drawing on rever a side.Signed X Title: �� AAt, Date: R RTMENT U5 Y Application Accepted by X= UAkhS rea Stk 466-6781 Additional Comments: ] Lodi 369-3621 Pit or Grout Inspecti Date Manteca 823-7104 Final Inspection by Date Cp Tracy 835.63B5 Applicant - Return all copies tonvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO- EH 13-24 REV. 10/82 10/82 500 14-26