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� s APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1501 F. HAZELTON AVE., STOCKTON, CA PERMIT NO, 3S Telephone (209) 466-6751 i DATE ISSUED —71 l� 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name Cj Address 40 ROSSHORE AUEOPUF . 3'S 00 ___ Phone Contractor's Name L W'F-LL Ut E License No. 571S(sO Phone w TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .� SEW& LINES `+ DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy -Dia, of Well Casing i Public t I ❑ �j Other ❑ Delta Irrigation r Type of Casing p I—i 9 Approx• Eastern a Cathodic Protection Depth j Specifications Depth of Grout Seal 4 Geophysical i Type of Grout LJ Other 4 Surface Seal Installed by Repair Work,Done IC Type of Pump �� H,PF 3 State work Done ZL)-%l*LL- Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW-INSTALLATION L_J:- REPAIR/RDDITION ❑ (No septic tank or seepage pit permitted if public sewer is — # available within 200 feet.) 1 4Instar,lati-ionrwil-l.-serve:,,Residence Commercial Other Number of living units: > Number of bedrooms Lot size ' 'Character of soiljto a depth fl 3 feet: _ _ _ Water table depth E SEPTIC TANK Type/Mfg t f' Capacity No. Compartments PKG. TREATMENT PLT, Type/Mfg t Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well. =o Foundation Property Line DESTRUCTION ❑ a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line w , SEEPAGE PITS ❑ Depth it Size., Number I SUMPS EJ Distance to nearest: Well Foundation Property Line- , y �. DISPOSAL PONDSED I hereby certify 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 licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is i s ed, I shall not employ any person in "such manner as to become subject to workmant compensation laws of California." Contractor' iring or s ontractin signat re certifies the following: "I certify that in the performance of the work for which this permit issued, I sha I em&ujd n ubject'to workman's compensation laws of California." The appl ' a ust call l rs ctiors Complete ding on rever e side. L` F• e Signed X `� Title: r Date: L..1 t/�. FOR Dt ART Application Acc ed b �8 rea _ lj 3 ❑ Stk 466-6781 Additional Comment . ❑ Lodi 369-3621 Pit or Grout Inspection by ' ate ❑ Manteca 823-7104 Final Inspection by 1'. ate { ❑ Tracy 835-6385 Applicant - Return alI i to: Environ ental H#a�,t# Permit/S vi b0 E. lton Ay ., P. x 20 , 5 , CA 952,91 f FEE BASE AMOUNT DUE AMOUNTf EMITTLD RECEIVED BY DATE PERMIT NO. INFO `l EH 13-24 REV. 10/82 j �y 0�$. 10/82 500 14-26 [ t'