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APPLICATION FOR:PERM?i 5F f+ JOAQUJft LOCA. hE .LTH Oi . ICT -F� 77 1601 E. HAZELTON .AVE., STOCKTON, CA PERMIT N0. Telephone {209} 466-6781 DATE ISSUED 2- PERMIT PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 1 (Complete in Triplicate) y i Application is hereby made to the San 'Joaquin Local health District fora 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 kegulations of the San Joaquin Local Health District. I Job Address P Subdivision Namer Owner's Name Name ,! Address a'c' L� �[y ' ,�7�]��"hone Contractor' License No. �s >� Phone i s , TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .CHER tL��. l , � DISTANCE TO NEAREST: SEPTIC TANK ` f �SEWERSL3NE'S "'pCSPOSAL Kr, I PROP`�lil w FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Industrial C]Open Bottom ❑Manteca Dia. of Well Excavation �J ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ) ❑ Public �s f ❑Other Delta ., � ❑ Type of Casing �"' u jrrigabi6n Approx. ❑ Eastern Specifications k `"`❑"CathodiXrb'tection- Depth Depth of Grout Seal ❑Geophysical Type of Grout U,Otherl tc Surface Seal Installed by 3 '{ t State Work Done Repair Work Done`G'— Type 'of"'Pump H.P. Weir struction [—I Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPT IC-WO,RK:'„v'NEW INSTALLATION REPAIR/ADDITION ❑ {No septic tank or seepage pit permitted if public sewer is > ` available within 200 feet.) O Commercial Other e , Installation will serve: Resident -,,:+--� ; ' t siz t Number of living um nits: Number of bedrooms __ Lo �� ` Water table depth Character C#.s011 toja depth of Z f t: apacity No. Compartments t5'EP1CwT4NK- yP /Mf9 - µ Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg' ' _ Capacity Property Pro Line SEWAGE SYSTEM Distance to nearest: Well ._ Foundation __IV rr p L DESTRUCTIONt-1 ! i Total length/size S�.L'EAOHING LINE -- �-"No+&Length of lines�J Distance to nearestWell Fourdation Property Line f�� FILTER BED ❑ es �. ___ - f size 'toe i Number SEEPAGE PITS Depth _ Distance to nearest: Well Foundation ��Q Prope.rt�y!Line�O SUMPS t 1 DISPOSAL PONDS ❑ {�, I hereby certify that 1 have prepared this application�andkthatythe work wi7i:;be done in accordance with5an Joaquin county ordinances,"state laws, and rules and regulations of the Sail-Joaquin Local Health District. Home owner or li ensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issue I shall not employ any person in such manner as'`to become subject to workman compensation laws of California," Contractor's ng or sub-contracting signat r ceFtTfie3 the"'fo9'lowing 1.1--certify that in the performance of the work for which this permi ssu , I shall emplo rsons bject to workman's compensation laws of California." The appli t -for r it i c£' ns. Complet .dr n reverse side. Signed X Title: Date: r FOR DEPART Stk 466-6781 Application Accepted by Area - �Lodi 369-3621 Additional Comment ❑ Manteca 823-7104 Pit or Grout-l-ns�ection by. Date ►► �� M ❑ Tracy 835-6385 F��nal"'Snspec£io`n fjy - `- Date `�]#Applicant - Return all copies o: Enviro mental Health Permit/Services 1601 Haze e., P.Q. Box 2009, Stk., CA 95201 ffAMOUNT REMITTED RECEIVED BY DATE PERMIT NO. FEE BASE AMOUNT, DUE - _ _- _ �-y :� --�—J- --.•-----•*•--��- - r "'".."" , ".'INFO - - - �`e'� s✓ i *.a}' ` �1 „ 3 93-77 10/82 500 EH 13-24 REV. 10/82 14-26