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APPLICATION FOR PERMIT i SAN J0411601 LOCAL HEALTH DISTRICT- 1601 E. NAZELTON AVE., STOCKTON, CA PE Hr111 MU. i -��YD ' ! Telephone (209) 466-6781 ty� w h lit l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE i55U[0 Io-►Z-• (Complete in Triplicate) ,31 Applicatioli is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein G described. This application is made in compliance with San Joaquin County Ordinance Mo. 549 for sewage or No: 1862 for well/pump r and the Rules and Regula tionsi of the San Joaquin Local ealth OS ict. , Job Address �.fD�(r, N, q(pjA t ub iv sion Name_ Amme� Name— Owner Na �www,a.Q sit* of Address.�d�fllQ - __ Phone 7L $� 7= Contractor's Name Fg"Ae.*j__ License Phone 04- TYPE OF WELL/PUMP WORK: NEW WELL CI WELL REPLACEMENT-Q �w DESTRUCTION Q PIMP INSTALLATIOM [J SYSTEM10AIRr I [7 1 } OTHER -0- DISTANCE UDISTANCETO NEAREST: SEPTIC TANK tj SEWER ONES DISPOSAL FCD. PROP. LINE 1 FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t )] Industrial Open Batton C MantecaDia. of Well Excavation ! 5 Z <J Dourest is 7Priva to Gravel Pack ❑Tracy ❑PuDIiG ! Dia. of-Well.Casing Fj Other ❑Delta �• • '� ,v Type of Casing Lj Irrigation Approz. Eastern Y - 1 �I ❑ . Specifications Depth ' .� t Cathodic Protection s i A ( /1 Depth of Grout Seal (J Gea4fiys meal Type of Grout t 5 ❑Dtne'r !' / Surface Seal Installed by Repair Work Done ❑ Type of Pump f H.P. - State Work-Dane— Wel I ork-Done—Well Destruction ❑ Well Diameter Sealing Material (top 50') t • 1 !� Depth s Filler Material ` TYPE OF!EPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑'j No'�9eDElc tank or seepage pit permitted if public 5ewer"is I,1 t., available within 200 feet.l . Installation will serve: Residence Commercial Others-- •u ' ]?I ` r, �..� Ja.n �I wo Number of Ifv ing units: Number of bedroimmi- lit si3�'� r_ a .Character of soil titd,a deot8 of 3 feet: - Q6fi y Hater table depth SEPTIC TANK r y Type/Mfg �d� p4<w� Capacity �'�.�0 :No. Compa rtmrnts PKG. TREATyENT PLT. ❑ Type/Mfg I k 1 Capacity _ Method of Disposal 1 SEWAGE' YSTEM Distance Co nearest: Well ,m FoundatioW ,Property Line DESTRUCTION ❑ 2.0 -r LEACHING LINE No, a Length of IIres — B l Totalvlength/size ��n , J' FILTER REO Distance to nearest I Well �Q� r Foundation_ '!. Property Line ^lip SEEPAGE PITS Depth Size ar a NunGe?/h, +� SUMPS U Of stance'[o nearest: Well Foundation .rS^ Property Line =..CJ_dD � ^ - r DISPOSAL PONDS ElI I Hereby certify that 1 have prepared this application and that the worK will be done in accordance with San Joaquin county f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licedsed agent's signature certifies the folJ"ing: "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 workmank compensation laws of Cali-forniai" Contractor's ,ring or sub-contracting signature certifies the,following: "I certify that in the performance of the work for whch this permit -.issued, I shall employ sons ,ject .ro w'pr n�s.+compen sa tion laws of California." The app] t all f;0011 re I ion CompI on reverse side. Sign X Title: Bate:�a•"c '/'7 J FOR DEDARTMENT USE ONLY ! App'lillation Accepted y Area ❑ Stk 466-6781 a Additional Comments: _ LAE k Lodi 369-3621 Pit or Grout Inspection •t" 4 to ❑ Manteca 823-7104 Final Inspection by D to Tracy 835-6385 - Applicant - Return all copi to: In ronmental Health Permit/Services 1601,1. Hheiton Ave., P.O. Box 2009, Stk., CA '95201 '.ftm" FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVEDI BY DATE PERMIT NO. INTO - LIS I EH 14-26 - -REV.-10/82 I 7g2"S� w � �