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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �/ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.�_-/O�L Telephone (209) 466-6781 DATE ISSUED "T" ""-ERMIT EXPIRES 1 YEAR FROM DATE ISSUED ?i4u q,,8t'_J00 !f /(Complete in Triplicate) 12Z - f 2 ApplicationYis hereby 'made to t e J cK, aIt�W4A �r r��to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 fore Qr No. 1862 for well/pump ; and the Rules and Regulations of the San Joaquin Local HealthDistr n C 4crA Aj / / Job Address ✓ - - ' f Owner's Name�1�Y�S/j�1/� S6�'Vl�� Address (/-JwA 1104F Phone :- t kf Contractor's Name ; rc (Alo. Phone TYPE OF WELL/PUMP WORK: NEW WELL WECL REPLACEMENT [ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LL OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK �Q� SEWER LINES DISPOSAL FLD. /jQJtLPROP. LINE FOUNDATION 4 •� *. AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial ❑ Open Bottom D.Mariteca 4'%. Dia. of Well Excavation f2 estic/Privateravel Pack {Tracy Dia. of Well Casing l Public I ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications t Cathodic ,Protection Depths € s ❑ . 3 Depth of Grout Seal ❑Geophysical i !:. 1 Type of Groutt Fifll79L/�!'� LJ Other 4 AL Surface Seal ]Installed by i Repair Work Done L] Type of Pump I H.P. 4 kState Work Done Well Destruction U Well Diameter I Sealing ,Material (top 50') i Depth = Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ei REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is ! available within 200 feet.) I Installation will serve: Residence — Commercial Other !�r Number of,living units: Number of bedrooms Lot size Characterofsoil to a depth of 3 feet: °r Water table depth (f t ❑ SEPTIC TANKXType/Mfg F. Capacity No. Compartments r� PKG, TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION i ❑ LEACHING LINE- ` ❑ No. & Length of lines Total length/size FILTER BED4 ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS Lj 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 i.n 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 compensat.' ]'d=-,4f Calif:nia." Contractor's hiring or sub-contracting signature Certifies the following: "I certify that in the performa��-fflf e work frZ.d*r.,+hich this permitlis issued, shall employ persons subject to workman's compensation laws of California." Lf gv The applica ust al for 1 required inspections, Complete drawing on reversekside, f �k D: _- Signed X Title:• -D ' s ..4 �, . DEPARTMENT USE ONLY Application Accepted by Area Stk �.4b6-6781f s :, Lodi J69,-3621; C Additional Comments: ❑ v i3 Pit or Grout Inspection by Date '� ❑ Manteca*823-7104 py ¢f Final Inspection by Date Tracy P.O. Box 200 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., 5tk CA 95201 nINFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. �� 9S �I3° - 10/82 500 EH 13-24 REV. 10/82 f 14-26