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APPLICATION FOR PERM:' SAN JOAQLIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -61A- Telephone u_Telephone (209) 466-6781 DATE ISSUED 3jTr�F Lf PERMIT EXPIRES 1 YEAR FROM DATE 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 and Regulations of the San Joaquin Local Health District. Job Address �, Oi 46 'SS M�Fn.7/yt�R� Subdivision Name Owner's Name �G ,Q?5 C,cG P.9A',%'� Address /.16'G " S MRri7yvl� lP Phone Contractor's Name Q I- License No. 7 67e4i- T-7 Phone .2 3 x//2 3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial [J Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private E]Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal c� ❑Geophysical Type of Grout �1 ❑Other Surface Seal Installed by 0-\ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Y Other Number of living units: Number of bedrooms Lot size .� Character of soil to a depth of 3 feet: Water table depth (1) SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal l SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line C DESTRUCTION C] LEACHING LINE ❑ No. 8 Length of lines /O X91 X 7 X[O Total length/size _ FILTER BEDWDistance to nearest: Well �FoundationT Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 workmans compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant �mmuust ca f 11 rr q fired inspections. Complete drawing on reverse side. Dater Signed X�z -, .& fr Title: rC 4c%" r FOR DEPARTMENT USE ONLY Area __;tom - EJSok 466-6781 Application Accepted by 7 ❑ Lodi 369-3621 Additional Comments: Date i nteca 823-7104 Pit or Grout Inspectio by /`l\ Date Tracy 835 -6385 Final Inspection by. P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies . o:� En vi onmeri}ait Health Permit/Services 16"E. Ha el , n Ave., FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. , INFO - ay- 10/82 500 EH 13-24 REV. 10/82 11 14-26