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{ APPLICATION FOR PERMT t SAN JOAQCiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON; CA PERMIT NO. 5- q 3 r Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 L 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 off the San Jcaqui Local H It District.. Jab Address /V x �1diyision Name 1 --- 3 Owner's Name Address �2,/an //,t, A Phone Contractor's Name WiQTIF,,_0 License No. O—Zi phone u w TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U x PUMP INSTALLATION J4� SYSTEM REPAIR- L7 OTHERU W� DISTANCE TO NEAREST: SEPTIC,TANK _+ SEWER LINES DISPOSAL '[LD' - -PROP. LINE 1 } F FOUNDATION �p/J f AGRICULTURE WELL OTHER WELL PITS/SUMPS /,g-D�,� _ y_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J J Industrial U Open Bottom Manteca _Dia, of Well Excavation JDomestic/Private50Gravel Pack Tracy Dia,,of Well Casing �] Public D Other Oelta Type of Casing - �_ V Irrigation .700 Approx. E] Eastern Cathodic Protection Depth _ Specifications Depth of Grout Seal T Geophysical Type of Grout Other Surface Seal Installed by P/5L11FR V&j .lam ,0l Repair Work Done FJ_ Type of Pump , �SLJ46 N.P. State Work Done A: 1 r Well'-Destruction ❑ Well Diameter Sealing Material (top 501) s3 Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200„feet.) Vv Installation will serve: Residence Commercial Other 's I Number of living units: Number of bedrooms-;�: Lot'size Character of soil to a depth of 3 feet: Water table depth ]Z7 SEPTIC TANK Type/Mfg _f Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg _ Capacity Method of Disposal f SEWAGE SYSTEM Distance to nearest: Well ""Foundation Property tine DESTRUCTION ! — �, LEACHING LINE ❑ No. & Length of iines Total length/size I k FILTER BED ED Distance to nearest: Well - Foundation Property Line f SEEPAGE PITS F-1 Depth Size Number { SUMPS r 11 Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS I 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.” Contractor's hiring or sub-contracting signature certifies the following: "I certify 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 applicant J fIor al required inspections. Complete drawing on reverse side. Signed X _Title: Date: - T 5 Y ACL0�� Application Accepted Area —� _ ED Stk 466-6781 Additional Comments: _ n A Lodi 369-3621 Pit or Grout Inspection b Date lr M..� Manteca 823-7104 Final Inspection by Date Ol?- ❑ Tracy 835-6385f Applicant - Return all copies to:# Environmental Hea th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA k95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO If_P_ q3- 1 10,D_ EH 13-24 REV. 10/82 10/82 500 14-26 iR9-