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r � s, .Y d APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT. PERMIT 8�_ b83 1601 E. RAZELTON AVE., STOCKTON, CA / Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR.FP.OM 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 herebapplicy to t made incompliance with San Joaquin County Ordinanc'No. 549 for sewage or No. 1862 for well/pump and the Rules and Re ulations of th San Joaq in Local Health District. Job Address �f! s / S bdivision !lame - Q Address > �- 32 f Phone Owner's Name /� air^ ,. 3� Phone Contractor's Name S� _License No. TYPE OF WELL(PUMP WORK: I! NEW WELLCJ WELL REPLACEMENT DESTRUCTOTHERN PUMP INSTALLATION SYSTEM REPAIR L] PROP..LINE�. S SEWER.LINES DISPOSAL.,FLD.r�+►'�"� DISTANCE TO NEAREST: SEPTIC TANK ---.—DISPOSAL., �- r___�; w- - OTHER WELL PITS/SUPWS 9' FOUNDATION AGRICULTURE WELL — CONSTRUCTION SPECIFICATIONS. INTENDED USE i� TYPE OF WELL PROBLEM AREA b F-1 j Industrial OpentBottom Manteca �}-Dia. of Well Excavation'"+• �'-•�'� * - } i Domestic/Private iE Gravel%Pack Tracy P. *,Ola. of Well Casing [' Public II �Other (�Deltas1�0 eType of Casing Irrigation I! 'N Eastern' ❑Eastern Specifications ti Cathodic Protection ;! Depth f4 Depth of Grout SealR4L r (]Geophysical ! �+ � ,t«' � Type of Grout t Other *;4ye�"' Surfzce Seal Installed by'; <"=.r`' art. l State Work Dane ; Repair Work:Done G Type of Pump H:P- Well Destruction Lf hell Diameter $eal ing Material((top�SO'') Depth `a t' Filler Materia I(Below 501 E OF SEPTIC WORK: NEW'INSTALLATION REPAIR/ADDITION�E]%V46 septic tank or seepage pit permitted if public sewer is , available within 200 feet.) Ts it _ installation will serv2:V"Residence IX Conanercial 2Other �� 3 Lot'Size Number of living units.��_'Number of bedrooms_ s:�r k �► Water table depthR Character,.of,soil to a,depth of 3 feet:�� ts � � SEPTIC TANK ,y Type/Mfg �1K" CapacitylB 4+ too. Compartment , C �!'� Method-of Disposal ' PKG. TREATMENT PLT. (� h Type/Mfg Capacity -� Distance to'nearest: Well y5 r FoundationProperty Line ) o 3^ /� Total length/size LEACHING LINE �' h, No. 8 Lef�gth of linos f ' � ,' . Property Line f FILTER BED �G Distance to nearest:, Well Foundation SEEPAGE PITS �] Depth Size '�• Number SUMPS LJ Distance to-nearast:�Ylell Foundation'. Property Line DISPOSAL PONDS [, �j }' I hereby certify that I ;have prepared this application and'-that the work,will be donelin accordance with San Joaquin county ordinances, state laws, And rules and regulations of,the San Joaquin Local Health District. At 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 hi sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I'•shalI employ.persons subject to workman's compensation laws of California. The applica tea for ions. Complete drawing an reverse side. t__- j ]_ 72'� Signed Title:i3 �Date: 'a OR MENT ISE ONLY NArea Stk 466-6781 Application Accepted by Lodi 369-3621 Additional Comments: u „ ❑ Manteca 823-7104 Pit or Grout Inspection by Date ,} J Final Inspection Eby -`:r_ - ti: Date Tracy 835-6385 E Applicant - Return all copies t1 0:' Environmental Permit(Services 16D1,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' yl' PERMIT NO. FEE" SASE�; ? AMOUNT;,DUE ' AMOUNT_ REMITTED RECEIVED BY f DATE / I N FO w W %.: �I 1 •<, � ��z ��b�✓� EH 13-24 14-26 REV 10/82 i, / `