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a ~' APPLICATION FOR PERMIT ,/ .f s ,�,.,.,y,r•'; s SAN JOAQUIN LOCAL HEALTH DISTRICT �3-'�0D�3/fj(tq 1 1601 E. DATE ISSUE HAZELTON AVE., STOCKTON, CA PERMIT NO., mi� Telephone (209) 466-6781 9 7 PERMIT EXPIRES ;'YEAR FROM DATE ISSUED D � !� (Opmplete in Triplicate) Application is hereby make 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 !-Il Re matior;,6� t1he Joaquin Local.}Heal% D'strict. / Job Address 7 �C� /V' L 1 •P/lY�.•&�A><'l:� S sion Name ' Owner's Name Address Adie 4k Phone Contractor's Name��l o Phone 7� -.j�3G}� TYPE OF WELL/PUMP WORK; NEW WELL ELL REPLACEMENT ❑ DESTRUCIION❑. OQ ' PUMP INSTALLATION � SYSTEM REPAIR ',:❑ OTHER [) LJ W DISTANCE TO NEAREST:. SEPTIC TANK 0SEWER LINES 40' DISPOSAL FLO, /Fir u PROP. LINE _ 1 FOUNDATION _,&117 AGRICULTURE WELL OTHER WELL _PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C ❑ Industrial [440inT�ottom ❑Manteca Dia. of Well Excavation I 04aplbstic/Private, .,,�,Gravel lyPack ... Trac Dia of y�1 Casi g •..+w..:� - ++r p>ACS�'4R!"�S�tala. of all..Casli ❑Pablo - • ❑Other ']Del to �"'� Type of Casing _ �j r.?<,F.� ' ❑ Irrigation Approx, ❑Eastern 'Specifications Cathodic Protection Depth Depth of Grout Seal S�© OOtherysf cal Type of Grout Surface Seal Installed by � .� Repair Work Done 1] Type of Pump 3 H.P. ' a State Work Done Well Destruction [J Well Diameter Sealing Material (top 601) Depth . Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW,I NSTALLATION [3 REPAIR/ADDITION E] (No septic tank or seepage pit permitted if public sewer is T Q ' Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: i Number of bedrooms Lot size _ Character of soil to a depth.of 3 feet: Water table depth SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest:. Well Foundation Property Line DESTRUCTION ❑ 1(LC'�p��' LEACHING LINE (] No. 6 Length of lines Total length/size. e' ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMP.S.pm;,,d;a 0—„ ,,Dj,scanceygfEarest:.—Hal l Founpation ' DISPOSAL PONDS i III,I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. { ' Home owner or licensed agent's sIgnolure!certlfles 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 workmany compensation laws•of California.” Contractor's hiring or sub-contracting signature certifies the following: 9 certify that in the performance of the work For which this permit is issued, I shall employ ersons subject to workman's compensation laws of California." The applicant mmu call fo 11 required pections. Complete drawing on reverses So ' Signed X 4` , Title: Cz%J\ Dater .a FOR DEPARTMENT USE ONLY 1 Application Accepted by Area 40Z Stk 466-6781wa� j Additional Comments: Lodi 369-3621 t Pit or Grout Inspection by Date Manteca 823-7104 �( UVa �b2J Final I nspection by Date r e ❑ Tracy 835-6385 "f 1)/ 53 11 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEEI' BASE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �ef/R �3-1�a� lUO Ala EH 13-24 REV, 10/82 � ,y� .}}. (� 10/82500 ' .� .. 14-26 lA 7'*" Py. 7 ��