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APPLICATION FDR PERM!. SAN JOAQ6iN LOCAL H;:ALTU DISTRICT 1601 E. HAZELT0N AVE., STOCKTON, CA PERMIT N0. Telephone (209)(209) 466-6781 DATE ISSUED / S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED zA (Complete in,Triplicate) L)j Application is hereby made to the%an Joaquin Local Health District for a permit to construct and/or install the work herein l described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump I and the Rules and.Regulations�o/f the San Joaquin Local Health District. / I Job Address oz5r7�.� IiG L?rk�+� ►M _ Subdivision Name L o� i, Address P one Owner's Name p L ne ,3 q Contractor's Name License No. +` TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ d PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE .WELL OTHER WELL PITS/SUMPS r. _I.N.T.ENDED.USE__ ,_. -,' ...T.YP.E--OF.-WLL-L-. .PROBLEM-AREA -r CONST.RUCTLON4RECIFICATIONS - - - Industrial ❑j Open Bottom ❑ Manteca Dia. of-Well Excavation Casing ( ` ❑� Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well CasIN i ❑ Public ❑Other ❑Delta Type of Casing y . �❑ Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic+Protection Depth '~� Depth of Grout Seal ❑ Geophysical : Type of Grout O ❑y0ther �� Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction. �:e--We'll.~Diameter Sealing Material (top 50') - . ` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK.; NEW INSTALLATION XREPAIR/ADDITION ❑ (No septic tank or seepage.pit permitted if public sewer is available within 200 feet.) Installation will serve- Residence ✓ Commercial _ Other Number of. living units: — - Number of bedrooms Lot size ' / -a' Character of soil to a depth of 3 feet: -,_ Water table depth SEPTIC TANK Type/Mfg Capacity . Vd0 No. Compartments PKG, TREATMENT PLT. ❑� Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundatipn Property tine :DESTRUCTION F i c aQQ No. & Length of lines ) - Total length/size LEACHING LINE 9 f x FILTER BED ❑ Distance to nearest: Well /�0 Foundation Property Line z t permit is issued, I shall not employ any _person. ' Number 2— SEEPAGE PITS Depth ?Y/� y� Size s SUMPS EllDisance to nearest:�el'1 /4D Foundation Property Line DISPOSAL POND5 ❑ �� r h 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 WealthYDistrict. rformance Home owner or licensed agent's signature certifies the following: "I certify that in the pens the work for which this F -„ such..mans to become subject'to workmanl; compensation laws of California.” inner a I Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this peFmitnis:issued, I shall employ persons, to workman's compen ation _ laws of California." The applicant t al or all required inspections. Comp letedrawi n ev side.Title: 7— „Date: - Signed X �*✓ � = MENT USE ONLY Area d - ❑ Stk 466-6781 Application Accepted by 4 � rt Lodi 369-3621 Additional Comments: _ -- 823-7104 _Date _Pit or Grout Inspection b f a -'� L7 Tracy 835-6385 95201 Final inspection by f x. .: :Date Applicant -Return all copie tEnvlironmenta 'JHealth-P.ermit/Ser'vices 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA o: DATE PERMIT NO. j FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY if IN FO3 ! 17 �s X15• Da �C' -7 5,1 $� 10/82 500 Eh 13-24 REV. 10/82 14-26