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1 C 6' f APPLICATION FOR PERMIT 7 q- Q SAN JOAQUIN LOCAL HEALTH DISTRICT -3 q- (O , I } 1601 E. HAZELTON,AVE., STOCKTON„ CA PERMIT NO. t 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/o nstall 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 LoSiLl Health District. - Job Address > C-i Subdivision Name + Owner's Name R�.Ma� Address .I� w/a�c s� Pry Phone 23s—RZ40 1 Contractor's Name M g/y d- VJ 09 5 WAZ29,2611 No. ,�/ 7 2 Phone � OA TYPE OF WELL/PUMP WORK: NEW WELL 5Z WELL REPLACEMENT ❑ DESTRUCTION L PUMP INSTALLATION SYSTEM REPAIR OTHER 1` DISTANCE TO NEAREST: SEPTIC TANK y-t -SEWER-LI•NES.— +'�� "DISPOSAL^,FLD. PROP. LINE � C FOUNDATION ( AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom 1]Manteca Dia. of Well Excavation Domestic/Private ®Gravel Pack �Tracy � �ia. of Well Casing , Public Ej Other [] Delta i Irri ation �/ Type of Casing 'IT 42 /� /J19 LI 9 Approx, Eastern Cathodic Protection / Depth ( 4` �§ Specifications ) Depth of Grout Seal y Geophysical Type of Grout REAu S'n N J7',I �Other Surface Seal Installed by GRJ_ wA7EP ,OiQ1LL1/� i Repair Work Done ❑ Type of Pump Sul_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material+(top•'50")A"'' Depth Filler Material (Below 50') TYPE OF SEPTIC"WORK: NEW INSTALLATION [J-11 REPAIR/ADDITION U (.No septic-tank" seepage pit permitted if public sewer is -+�""""` J available within 200 feet.) YR?1RI. Installation will serve: Residence Commercial Othex ; —1.. — % Number of living units: Number:of bedrooms ,A:.• ,s -a'Lot size ik �i Character of soil to a depth of 3 feetA t 'Water table depth "SEPTIC TANK Cj Type/Mfg Capacity k Oo. Compartments PKG. TREATMENT PLT. E] Type/Mfg _ -� Capacity ' Y /Method of Disposal SEWAGE SYSTEMDistance to nearest: Well I Foundation Property Line DESTRUCTION Q LEACHING LINE No. & Length oflines i Total length/size FILTER BED Distance to nearest: Well FoundationyAtfProperty Line ' SEEPAGE PITS [] IDe'pth # Size t el a Number 4 1 4 ” . a, SUMPS U Distance to nearest.-,,Well Foundation a ;Property Liner •; DISPOSAL PONDS *[ 6P r 4 I hereby certi".fy 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"'foliowing: "I certify'that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation la-ws-of California." �,Tfte applicant must 11 for all required inspections. Complete'drawing on reverse side. €ter r-• Signed X Title: t Date- FV ate:F K DEPARTMENTiU ONLY ! Application Accepted by reaz� `�T r�St` k 466-6781 . VP ;-a Additional Comments: 1 (] Lodi 369-3621 fi —Pit or Grout Inspectionby R f [Date. :' - �� Manteca 823-7104 U Final Inspection by " J 'Date u r 1 �{ Tracy 835-6385 Applicant - Return all copies to; vironmental HealthiPermit/Services 1601 E. Hazelton Ai?, P.O: Box 2009, Stk„ CA 95201 f I PII�' FEE BASE *AMOUNT" DUE "AMOUNT`REMITTED RECEIVED BY -DATE PERMIT"NO. INFO � y EH 13-24 REV. 10/82 10/82 500 - 14-26