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/113 APPLICATION! FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTONAVE., STOCKTON, CA PERMIT N0. P-q Telephone (209) 466-6781 r I DATE ISSUED D-�r� 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local HealthlDistrict fora permittoconstruct 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 .�J�(y{, 6120 /4t01•Subdivision Name Owner's Name Address Hkyft75 5f5C.4,VW della i9 �rl�PnRho e ��--SSzG Contractor's Name "* License Flo.' Ph&W (� f � F TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT []' DESTRUCTION W 1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ti DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -F Industrial " Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ,i 0 Gravel Pack Tracy Dia. of Well Casing LF1 Publ is Ej Other Delta Type of Casing LjIrrigation Approx. Eastern Specifications ` Cathodic Protection Depth p Geophysical Depth of Grout Seal LJ Other Type of Grout {� Surface Seal Installed by 7p n✓ L Repair Work Done ❑ Type of Pump H.P. State Work Done ri! Well Destruction [—IWeil,Diameter Sealing Material (top 50') _ L�! Depth Filler Material (Below 50') L]a ,p 4 TYPE OF SEPTIC WORK: NEW.INSTALLATION� REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence _X Commercial _! Other Number of living units: ! Number of bedrooms Lot size f 2 7,2 .3 X r Character of soil to a depth of 3 feet; IM Water table depth 2�� 'r SEPTIC TANK ,Type/Mfg CQAjGIPETt PjLCDNc,-Capacity & (J No. Compartments EE PKG. TREATMENT PLT. E] Type/Mfg Capac qty Method of Disposal _ t SEWAGE SYSTEM 'Distance to nearest: Well IM Foundation Property Line DESTRUCTION M. LEACHING LINE ,No. & Length of lines 2 �'rj I Total length/size 7y FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS WJ Depth ,2 S Size � .�� Number Z t SUMPS lJ Distance to nearest. Well .. Foundation Property Line p DISPOSAL PONDS r I hereby certify--that I have prepared this application andithat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Lqcal Health District. r Home owner or licensed agent's signature certifies the following: "I certify that i.n 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." Contractor's hiring or sub-contracting signature certifiesIthe following: "I..Sertify that in,the performance of-the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applic t mustc 1 r all required inspections. Complete drawing on reverse side. _ Signed Title: 994AVA/fi4 Date: II QCT r-3 ,4 F E T USE ONLY Application ccepted by IM Area �f Stk 466-6781 r Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date 000-av-9—T Manteca 823-7104 Final Inspection by 'f Date/,0,a I/— b 3 L Tracy 835-6385 Applicant - Return all copies to; Environmental Healt er'mit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II FEE BASE AM NT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 i _. f