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R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTCN AVE., STOCKTON, CA PERMIT N0, 5 3_.3 B D 4 Telephone (209) 466-6781 DATE I$$UED I PERMIT EXPIRES 1 YEAR FROM GATE ISSUEDj -33 (Complete in Triplicate) ✓�[rs�$J' 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 Subdivision Name Owner's Name I Address ) Phone 9 e Contractor's Name f-)a. O 1,9=VL_ License No. 7J�J Z Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C� Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation Q Lf Domestic/Private ❑Gravel Pack Tracy Dia, of Well Casing ❑ Public ❑Other Delta r Irrigation Type of Casing Li 9 Approx. Eastern Depth Specifications Cathodic Protection p Depth of Grout Seal Geophysical F-1 Other Type of Grout Surface Seal Installed by `l°' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50')'^ W---- Depth Filler Material (Below 5O'f),. E _ i w .aa n�i -r i�ini.u. r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is I" �t availabl4 within 200 feet.) Installation will serve: Residence )� Commercial _ Other Number of living units: _� Number of bedrooms 2�— Lot size .9 L/-'K 7S Character of soil to a epth of 3 feet: StA ti , ' Water tableldepth SEPTIC TANK Type/Mfg C L -t Capacity ./�2 0 0 No. Compartments Z PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ ill LEACHING LINE No. & Length of lines _3 r..—`j Total length/size JC oZ FILTER BEDDistance to nearest: Well Foundation Property Line z SEEPAGEPITS7 Depth Size Number , SUMPS F "Distance to nearest: Well Foundation Property Line +^' # { DISPDSAL PONDS I�n.nr� 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 workman 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 all em Toy persons subject to workman's compensation laws of California." The applicant must cal or uire " spections. Complete drawing on reverse side. N ii Signed X " Title: Date: y " FOR DEPARTM ' Application Accepted _ Area Q �-'$tk 466-6781 Additional Comme s: • [� Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date — Tracy 835-6385 Applicant - Return all copies to: Environmental Health "Permit/Services-'l6 1-E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEE SASE AMOUNT DUE: AMOUNT REh1ITTED ,. , } ,IRECEIVED BY DATE PERMIT NO. !M1 INFO EH 13-24 REV. 10/82 -� 10/82 500 + 14-26 �