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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YF1R r1ON DATE ISSUED (Complete In Triplicate) _ YI Application is hereby made to the San J, juin Local Health District for a permit to construct and/or install the work herv.in described, This application n e a h n Joaquin Count Ordinance No. 549 for sewage or No. 1862 for wall/pump A, is made in mplia c t Sa oaq y 9 �. and the Rules and Regulations of the San,.,,aquin Local Health District, Al Job Address /j ubdIvision Name Y> t O+mer's Name Fd ,` �A,g1,14/1R AA Phone ,s i Contractor's Nasse Q�,j,�,(-�l License No. �1 7�/�s Z _Phan* TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLAJEMENT ❑ DESTRUCTION❑ W PUMP INSTALLATION [] SYSTEM REPAIR ❑ OTHER ❑ �• I DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINF. ' � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r i INTENDED USE TYPE OF WF'L PROBLEM AREA CONSTRUCTION SP4CIFICATIONt ^ I ❑Industrialen p Bottom ❑ ❑0 Manteca Dia, of Well Excavation ;;a•�;. v ❑Darestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing 5; ❑Public �IOther ❑Delta Type of Casing Irrigation Approx. ❑Eastern ❑Cathodic Protection De th Specirication3 P Depth of Grout Seal _ =;•' ❑Geophysical Type of Grout W,�+ ❑Other Surface Seal Installed by 4, Repair Work Done❑ Type of Pump H.P. State Work Done �j- Well Destruction ❑ Well Diameter Sealing :Iaterial (top 501) a , Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION[j REPAIR/ADDITION (No septic tank or seepage pit penHzi6te if public sever is - available within 400 feet ) Installation will serve: Residence JZ Commercial _ Other Number of living units: / Number of bedrooms _ _ Lot sizeA-V r Character of soil to a depth of 3,felt:- Water table depth {J� h SEPTIC TANK ❑ Type/Mfg Capacity No. Copparteents - a /l P.%. TREATMENT PLT.,❑ TYPe/Mfo Capacity Method of Disposal 3 �: Septic Tank Distance-to nearest: Well - Foundation .- Property Line I)estrLction13 LEACY.ING LINE ❑ No. S Length of lines _ _-Total tenth[ ize -FILTER BED [v�Distance to nearest.:-_ Well Oo fr FoundatiLtt ," Property Line. f6'a ' } SEEPAGE PITS ❑ Depth Size Number !s ,JriPS ❑ Distance to nearest: Well _�Foundation Property Line ' r;r DISPOSAL ?ONDS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ...1` sh ordinances, state laws, and rules and regulations of the San Joaquin Local 14ealth District. Home uwner or licensed agent's signature certifies the following: "I certify that in.the performance of the work for which this . . , California." permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of i Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which !- syi' this permit is issued, I shall enploy persons subject to workman's compensation laws;of California. -• _,r� r,-.!;; Y1i^ 'The applicantt call for all required inspections. Complete drawing on reverse side. rc'3 t •' Signed X `�,7�i,�;L.r/L Title: ��..rwC� Date: 1 � � FORO,r�g�2TMF USE 0l:LY S Applicati •i Accepted by /f'LYh* Area A ❑ Stk 466-6791 Additional Comments: ❑ Lodi 3694621 i1 `\` y• + Pit or Grout Inspection by Date..... ❑ Mentees 823-7304 j Final Inspection byDate 7_72z 41 CJ-Tracy 835-6386 Y -if -�"- Applicart - Return ali copies to: Environmental Hea ermit/Services 1601-E. Hazelton Avg., P.O. Box 2009. Stk., CA 96203 ' FEE BASF. AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT iNCH INFO- - �� EM 13-24 REV. 10/82 1 /1 3 10/82 500 +. -- -- —1446 .+ -w.r....r.�..wmoi;:i.z �..;..a.-.... - sir/.s�«.:u..�i:.,�.:+fin`ia^Xt•C(by.`t•.. �•..• r.:;�� N4r4�