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"1 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 7 (� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Z,3— / Telephone (209) 466-6781 DATE ISSUED 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 3Y y/°7 S• Kos fey 17-t• Subdivision Name Owner's Name /309 a Tr I, jgg- . Address �yJi} S KOS reY RoP. TYN�V Phone Contractor's Name O0�5o/Y License No. Y419'-�9/ Phone p�l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �,j 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 ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑Public ❑Other ❑ Delta Type of Casing — Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth - Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 sewr TYPE OF SEPTIC WORK: NEW INSTALLATION EJREPAIR/ADDITION Fj (No septic tank or seepage prtermi availaDleewithinu200c feete) is --�J Installation will serve: Residence _ Commercial _ Other Zj""VL Trilri for Number of living units: / Number of bedrooms / Lot size _4V.0Kf x.�" Water table depth -s'a Character of soil to a depth of 3 feet: r-A.Ay Ao /d No. Compartments SEPTIC TANK J�j Type/Mfg G ye Capacity /�O n Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg �\ SEWAGE SYSTEM ❑ Distance to nearest: Well XOO oO• Foundation .2�' Property Line i ��,,,ii1 DESTRUCTIONS L Total length/sue 'Opp" 7D - LEACHING LINE FS_J No. 6 Length of lines i FILTER BED ❑ Distance to nearest: Well 54.10 ' Foundation .70' Property Line Number SEEPAGE PITS [J- Size Depth Property Line SUMPS ❑ Distance to nearest: Well Foundation 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 workmant 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 ,muuu call for all required inspections. Complete drawing oside. Date: ).%-!`/- 8'J Signed X d '7Ni'rd Title: b �7a //1/��,�,, FO EPARTMENT USE ONLY Area E]❑ Stk 466-6781 Application Accepted by 4&e _ ❑ Lodi 369-3621 Additional Comments: ❑ Manteca 823-7104 Pit or Grout Inspection b Date 2 Date j ❑ Tracy 835-6385 Final Inspection by - P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environ al Health Permit/Services 1601 E. Hazelton Ave., rFEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. O 1a a1-�3 83-13cl 4 415 10/82 500 EH 13-24 REV. 10/82 14-26