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w f l APPLICATION FOR PERMIT SAN �OAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ` 3 DATE ISSUED !.:A s_I � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (. omplete in Triplicate) E xD . I 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 I and the Rules and Regulations of Phe San Joaqujn Locdl Health District. Job Address �10t C`fl 2 R 9C)G�sI+CSubdiv`ision Name Owner's Name �CS � Address 7� �ZIC S (,J F Phone j - 00 Contractor's Name {ticense No. Phone 0 8 O TYPE OF WELL/PUMP WORK: NEW WELL E]" WELL REPLACEMENT ❑ DESTRUCTION ❑, PUMP INSTALLATIONSYSTEM 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 SPECIFICATIONS17 I Industrial Open-Bottom ❑ -Manteca" " ^" Dia:-of-Wefl-Excavation'- ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ,] ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal (� L❑Geophysical Type of Grout N ❑Other Surface Seal 'Installed by Repair Work Dane E] Type of Pump H.P. state Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ] REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted ifpublic ailable within 200fsewer }s Installation will serve: Residence _ Commercial Other Y � . Number of living units: Number of bed ooms Lot size /17 Character of soil to a depth of 3 feet: Water table depth Capacity OO No. Compartments 4 SEPTIC TANK Type/Mfg C NY�vs� pacy PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSProperty❑ Distance to nearest: Wel] Foundation y Line k DESTRUCTION ✓ i I -- - - --- 11� LEACHING LINE No. & Length of lines -_ /X5Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �Property Line SEEPAGE PITS ( Depth2��- Size' I (Number L SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �._ i �, _ ` # y _ e I hereby certify that I have prepared this iapplication and that the-work will be-done Jn,-accordance with San Joaquin county ordinances, state laws, and rules'and`y egul.ations of,the SanlJoagQ Local Health District. Home owner or licensed agent's signatur.e.c6rtifies the following; ''I certify that in the performance of the work for which this `s permit is issued, I shall not employ a,ny,_person in such manner,as..,to become subject,to workman compensation laws of California," f Contractor's=.hiring or sub-contracting signature certifies the'following'. certify that.ithe performance of the work for which this permit i5: issued,l shall employ person's subject to workman's compensation laws-of-California." T ' The applicant �tcal�lrequired inspections. 'Gomplete drawing on revue { ' 1 Date: !� �O Signed X Title: FOR EPART NT USE ONLY Stk d56 b781 _ --_ Application Accepted by �` L ,y Area Ad ional Comments: SIS J i1731�/rP 1J�o�j�: QL�C°�� « ❑ Lodi 369-�3fr21�~ w�.�. �: �J• e _- U Manteca 823-7104 Pit or Grout inspection by _ Date �� ❑ Tracy. 835-6385 Final Inspection by 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA } FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. 1. INFO .1: ��..4 .•'C �ti 1 0/82 500 EH 13-24 REV. 10/82 i ��- rt „ _� -. �• . .ew /��l�C /dL�� . IA-26 C��ni