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APPLICATION FOR PERMIT 14 SAN 1OA1111 LOCAL HEALTH DISTRICT a r10 `8 l% Off 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. i Telephone (209) 466:1.6781• ,f DATE ISSUED Y r\ 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/or install the work herein ' {{{ described. This application is made in compliance with San Joaquin County Ordinance No. 541 for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Hea!S,.b+,-KW,'1on Job Address /a,��3 E, 640OX,!t4l" 4'T Name R. /'�. /,/ O 57 Owner's Name �NV�!//h AddressS1QsrlG Phone :^ Contractor's Name FL.G L� F� t4&&2> License No� 447tr2,76 _ Phone +4S-3 9 7/ 1 TYPE OF WELL/PUMP WORK: - NEW WELL WELL REPLACEMENT DESTRUCTION�f PUMP INSTALLATION (] SYSTEM REPAIR OTHER r DISTANCE i0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF-WELL PROBLEM'AREA CONSTRUCTION SPECIFICATIONS L 17 Industrial Open Bottdm'~`'❑Manteca , Dia. of Well Excavation LJ Domestic/Private Gravel Pack Tracy ` + Dia:' of Well Casing — .e o Public �Other �Delta �.�•�_Type of Casing U Irrigation Approx. []Eastern Specifications f w Cathodic Protection C1 ep . " Depth�of'Grout Seat Geophysical Type of Grout Ah L_1Other - ; s' .� € Surface Seal Installed by , f. Repair Work Done[� Type of Pump H . Stater Wark Done � Well Destruction 7j Well_Diameter o Sealing Mater w,(top 60') Depth + Filler Material !(Belowr50')' { , , r TYPE OF SEPTIC WORK: NEW INSTALL TI REPAIR/ADDITION ❑ (No septicitank-or seepage pit permitted if public sewer is_. •� +' available within 200,feet.)• Installation will serve: -Residence Commercial Other f r Number of living units: Number'of bedroomsr Lot size j �4C Character,.of soil to a depth+of�i feet: 4/We 1 Water table depth SEPTIC TANK Type/Mfg;��°; /�i¢ 4. capacity" 12 No. Compartments 2' cam' 1 i Method of Disposal M. TREATMENT PLT. � Type/Mfg _-•.�. Capacity.. SEWAGE SYSTEM 'to nearesty Well Foundation •Zy Property Line _ DESTRUCTION Q „Distance - LEACHING LINE No. 8 Length of„lines x'Z' g Total length/size ��zQ Jr Z ''”fILTTER BED [�, Distance to nearest: •Weth;�/ � Foundation �d 1 Property Line SEEPAGE PITS Depth, .+a1'.S� Size Nei 3 3 �� Number Z F SUMPS w �` -;�' Distance�to nearest: Well _ Foundation /�-S Property Line DISPOSAL PONDS, ❑ t.at ti• r-„.�.,:�._... ,�,,,,,,,,.� f ! •.�'� I hereby certify that I •have prepared thi,s application and:that'jthe 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 Iicensed,agent's signature certifies the'oj.owing• "I certify that in the performance of the work for which this. permit is issued, I shall not employ any person in,sucli'manner as to become subject to workman 5 compensation laws of California.” contractor's hiring or sub-contracxing signature certifies the following:• "I certify that in the performance of the work for which this permit is issued,,I shall employ persons subject to workman Is=comp�sation laws of California." The applicant must call for all required i spections. Completeldrawing on reverse side., _ k ��_ I Date: -' F Signed X Title: } j�� RTMENT E LY till Application Accepted by 1 �!�(! y 3 Area — Stk 46b-b781 Additional Comments _ ? Q Lodi 369-3621 Pit or Grout Inspection by T Date ° Manteca 823-7104 # Final Inspection by "" Date L7 Tracy 835-6345 Applicant - Return all copies to: Environmental Health Permit/Services 1.601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 ------------------------------- t FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY` DATE PERMIT NO. INFO U 3" t EH 13-24 REV. 10/82 10J82 500 14-26