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n APPLICATION FOR PFRM!T k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 72:-U Telephone (209) 466-6781 GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicati6n'is hereby made to`the San Joaquin Local Health District for a 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 Regulations 9f the:San Joaquin Local Health District. Job Address '�� J_Al. 4�,61 Subdivision Name Owner's Name /QIJ$8&2 GE71 r � Address / 2 1/ PhoneUJ Contractor's Name 0M!&:S#-4 License No. Phone — I TYPE OF WELL/PUMP WORK: NEW WELL I] WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U 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 ro Industrial ,l Open Bottom Manteca Dia. of Well Excavation LJ Domestic/Private Gravel tPack ❑ Tracy Dia, of Well Casing w Public Lj Otherj D Delta Type of Casing g Irrigation Approx. L] Eastern Specifications Catodic Protection Depth [� hPttiDepth of Grout Seal L7 Geophysical i, t Type of Grout c- U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done well Destruction Well Diameter , Sealing Material (top 50`) •* x Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIR/,ADDITION (No septic tank or seepage pit permitted if public sewer is " available within 200 feet.) Installation will serve:. Residence V Commercial _ Other d Number of living units:~ Number of bedrooms Z_, _.__ Lot size _Atm� Character of soil to a depth of 3 feet: LG51!!1 Water table depth p V SEPTIC TANK L! Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg t ' Y. Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines -0/ Total length/size _ J7� FILTER BED Distance to nearest: Well __474a� Foundation _ Property Line SEEPAGE PITS Depth -- Size _ Number t SUMPS L—� Distance to nearest: Well undationQ "bperty Line ,_ 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 erson in such manner as to become subject to workman compensation laws of California." Contractor's fiiring or sub-contracting gnature certifies the following: "I certify that in the performance of the work for which this permit is ' sued, I shall emplo ersons subject to workman's c pensation laws of California." The applic call fo all ed ins c o ons. Complete dr ng on evAise sides—` Signed., i Title: . Date: FOR DE TMENT USE ONLY Application Accepted b - Rrea Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date �� Manteca 823-7104 Final Inspection,(by > Date 5 - � ❑+Tracy 835-6385 Applicant _,turn ad'l.copies to: . Environmental Heal h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., -CA 95201 i FEE BASE AMOUNT DUE, AMOUNT REMITTED RECEIVED BY DATE PERM�iT/N0. INFO 10/82 500 EH 13-24 REV. 10/82 14-26