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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS ( `� 1601 E. HAZELTON AVE., STOCKTON, CA 'a PERMIT N0. p1 2 Telephone (209)'466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) v , 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 Joaq in County Ordinance No. -.549 for sewage or No. 1862 for well/pump and.the Rules Reg l�at/ions of the San Joaquin Local He.�rith trict. Job Address �7 W � ✓�-IN Atilt vision Name sy - e Phone Owner's Name MRS 3LlTt ddress 23-bs$y ` Contractor's Name /Ir," C!4.12Co�lC License No. �(311 Phone TYPE OF WELLIPUMP WORK: NEW WELL WELL REPLACEMENT 0 DESTRUCTION (14 ' '• ) PUMP INSTALLATION (� SYSTEM REPAIR 0 OTHER U DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION !I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L i J Industrial U Open Bottom • []Manteca. ! Dia. of Well Excavation p� \ ZJ Domestic/Private ��]Gravel Pack _ �Q.Tracy_ _�- Dia. of Well Casingy.....� F 17 Public [-)Other 4 Delta Type of Casing j Lt Irrigation Approx. Eastern Specifications [�Cathodic Protection Depth Depth of Grout Seal j Geophysical Type of Grout ' ❑Other Surface Seal Installed by -Repair Work Done [] Type of Pump J H.P. State Work Done Well Destruction 17 Well Diameter- Sealing Material (top 50') - Depth Filler Material (Below 50') �r n sewer TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION (No septic tank or seepage p�availableewithinu200cfeet.) is v` Installation will serve: Residence 41( Commercial _ Other Number of living units: Number of bedrooms _ - Lot size 2 �� Water table depth Character of soil to a depth of 3 feet: L Or�l�1 No. Compartments ' r Capacity ~ SEPTIC).TANK,--�J-TYPe/Mf9' Method of Disposal PKG, TREATMENT PLT. 0 Type/Mfg Capacity Foundation Property Line SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION �0 ,= Total length/size ` LEACHING LINE �j No. & Length of lines i F fF Property Line O FILTER BED Distance to nearest: Well Qt>_ Foundation D —.------ , ` Depth F Size ```^"-Number-• j SEEPAGE P1TS'. -Proper-t. Line ( SUMPS F-1 Distance to nearest: Well Foundation If DISPOSAL PONDS LI be donin nce with San Joaquin county I hereby certify that I have prepared this application and that the work will e accorda R ordinances, state laws, and rules.and regulations of,the San Joaquin Local Health District. ce;of the' Home owner or licensed agent's signature certifies suchifmannernas to become subjectthat ntohworkman�comb nsatianwlawshe California."i permit is issued, I shall not employ any p r Contractor's hiring or sub-contracting signature certifies the-following: "I certifyon laws that in the performance of the wdrk for which of California." this permit is issued, I shall employ p ..T..,...... -----a-••�^•, The applicar�st call for all requir inspections. Complete drawing reverse side. Date: ' D Signed X &I.%, Title: ; ! PARTME E ONLY R �] Stk 466-6781 Application Accepted by Area t Lodi 369-3621 Additional Comments: El Manteca 823-7104 Pit or Grout Inspection D Date �/ Date T. �- tT � Tracy 835-6385 Final Inspection by CA 95201 Applicant - Return all copies to:. EnvigIrron al Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, St k., v PERMIT NO. a E. FEE BASE. AMOUNT ,DUE AMOUNT REMITTED • RECEIVED BY •.DATE p INFO ! ' j S• O o L'' !.l a-'93 1-3" t a-10 10/82 500 EK-13-24 REV. 10/82 14-26