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.........a.. - -- ---- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM GATE ISSUED (Complete in Triplicate) 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 and the Rules`a/n Regulations o he San Joaquin Local Health District. Job Address �C Bn �UUGA JjMoubdivision Name I Owner's Name CM Iti4t GA'"AO Hill Address^ Phone �yv�/Y $ '6S8W Contractor's Name Iidh 2 `ARO>Lt License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION❑ { PUMP INSTALLATION SYSTEM REPAIR OTHER :]DISTfANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS is { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( -� industrial Ej Open Bottom ❑Manteca Diaf,df Weil Excavation U Domestic/Private F-1 Gravel of,well Casing Gravel Pack �Tracy f {Public �j Other Delta Type of Casing ' v - Lj Irrigation Approx. ❑Eastern Specifications Depth ` E]Cathodic Protection Depth of Grout Seal p LJ ygyeophysical Type of Grout ' T? .� ther Surface Seal Installed by State Work Done i I \ Pep% Work Done ❑ Type of Pump H.P. rdell�Destruction (] Well Diameter Sealing Material (top 50') .,.,f Depth Filler Material (Below 50') • �. if .0) TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION "(No septic tank or seepage pit avai ableewithipublic 200fe t-1. 0,^ Installation will serve: Residence X Commercial _ Other Number of living wits; Number of bgdYrpoms �— Lot size / ACr",� 1 "u'Le�w, . ..- :I : TWater table depth 1 Character of soil o a depth of 3 feet:'`i S„JOY ) `i Capacity. No. Compartments SEPTIC TANK ] Type/Mfg ' ' Method of Disposal I Pd. TREATMENT PLT. 10 Type/Mfg 3 Capacity ;w SEWAGE SYSTEM ...�Distartce"o.near-est_Wel].,_ FAundation �_� Property Line DESTRUCTION I ' ps ,i I '. Total length/size LEACHING LINE gI No. 8 Length of lines, , Property Line D� f FILER1 BED Distance to nearest: Well oa Foundation SEEPAGE PITS ❑ Depth _ size ''.Number Property Line 3 t SUMPS Distance to nearest,;,,-WeJJ_._—.- Equpdatij}on P Y D[S OSAL PONDS ❑ _ L I hereby certify that I have prep8�ed this application and that he work will De done in accordance with San Joaquin county prd.inances,fstate Tawst an8-rules.and regulations of the San Joaquin Local-;Heal' District. ..«j Horne owner or licensed agent's signature certifies the follawj ngaw"I•chrt}fy`!at In a pe orlPdnce of'the'.work for which this Permit is issued, 1 shall not employ afiy person insucN ri 6er as to become subJe. to workman$compensation'1.aws of work California."whiw Contractor's hiring or sub-contracting.signarecertifies the following:"I certify that in the performance of the ;rk for which jt�hciirrs permit is issued,,,I.sha11-employ persons s4ect',Co workman's compensation laws of-�alifornia."� The'.2p icaniF't,Zltcat callforall req�i�ed inspections. Complete drawin on r se side.vL - Oat,: ` :s+ ^ Signed X f !. ��"'^1 Title: _ j _ ,y y Z/ ( FORr_P(�EP�ARTMENY.USE ONLY] ( / "+(]' Silk 466=6'/81`=`y a i Application Acceptetl by rlFllin �^� ' Area �G---- 1 (j Lodi 369-3621 Additional Comments: 4-�� { ,ys'Manteca 823-7104, .f Pit 6r Grout Inspection by' Date ' 1 n i Date —, _e� Q Tracy 835-6385 Final•�tnsPection^'by P,O, Box 2009, Stk.,t CA' 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazel on Ave., k ^ t ! PERMIT N0. ' FEE BASE `'� AMOUNT DUES AMOUNT REMITTED I RECEIVED BY DATE ' 10/82 500 ,r. • ', f''t'it.' 4 EH 13-24 REV. 30/82 `• 14-26