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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 . y i DATE ISSUED i PERMIT El(PIRES 1.YEAR FROM DATE ISSUED " (Complete in Triplicate) f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 ZS-Mr-A,1. Subdivision Name Owner's Name zAf11yMd It 4 P4.T4E Address J�PQ /-,j e,✓ vry Phone 772-17 _ /r Contractor's Name / ,.f�iFd itr./oY✓ rep , License No. -Z. p Phone 772. -Z Zof TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ r� PUMP INSTALLATION E] SYSTEM REPAIR OTHER [ ' DISTANCE TO 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 _ 17 Industrial U Open Bottom Manteca Dia. of Well Excavation t 17 Domestic/Private E]Gravel Pack Tracy Dia, of Well Casing 17 Public Other El Delta Irrigation Type of Casing LJ g Approx. �Eastern F-1 Cathodic Protection "+ P Specifications Geophysical ;- e. # Depth of Grout Seal � 14 Type of Grout �\ ¢ U Other ! v 41 Surface Seal Installed by Repair Work Done E]I ype of Pump H.P. State Work Done + Well Destruction U T Well Diameter ". ,. Sealing Material (top 50') x ,# ��Depth"""'IP � Filler Material (Below 50') 113 TYPE OF SEPTIC WORK:wNEW-INSTALLATION [X REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence�le- Commercial _ Other Number of living units: —� Number of bedrooms �j Lot size 1 �' r Character of soillto a-depth of 3 feet: �+ ""> Water table depth SEPTIC TANK �j Type/Mfg r Capacity (j;(JD No. Compartments :2- PKG. TREATMENT PLT.1. M, Type/Mfg¢; * d `» Capacity Method. of Disposal x Distance to nearest:,)Well'- Foundation Property Line LEACHING LINE No. &-Length of lines YU 1 _ Total length/size �� r FILTER BED Distance to nearest: Well _LQG* Foundation Property Line SEEPAGE PITS Depth «� Size _ 3'�d/st Number 1 p SUMPS U Distance to nearest:`Well loo Foundation Property Line _& "74- DI SPOSAL 74-DISPOSAL PONDS "t 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 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." 4 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in thte performance of the work for which this permit is issued,_ I sha employ persons subject to workman's compensation laws of California." The applicant st foyAlI required inspections. Complete drawing on reverse side. ✓ Signed K Title: C'O.v � Date: it-/Z 4 Z. !` .} FOR DEPAR MENT U NLY Application Accepted by �e� Area Stk 466-6781 Additional Comments: � Lodi 369-3621 r f Pit or Grout Inspection Date �' Manteca 823-7104 Final Inspection by Date �. Tracy 835-6385- Applicant - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 6 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO f c 1 ! d EH 13-24 REV. 10/82 I0/82 500 14-26 ,