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G APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA-, PERMIT NO. Y3--1165 Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED ' DATE ISSUED 16 - o � 3 (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 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.=ta San Joaquin Local Health District. Job Address Y Subdivision Name 1 .Ownei"s Aare"r �- G 1 Address Y J : R��t Phone Contractor's Name M4 Bk-rJNJ�k License No. Phone s TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT. DESTRUCTION �s,f PUMP INSTALLATION SYSTEM REPAIR OTHER E W ----DISTANCE TO-NEAREST-SEPTIC.TANK' = SEWER-L-NJES Dh3POSAL-F}{t ----- pR4P-L-I"NE ) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ] Manteca Dia. of Well Excavation U Domes tic/Pri.va.te:._-0_Gravel-Pa ck-- -- Trac - - " Public Other � y-�- -•-----w-Dia=nf�Well=Casing -" - - _ _ _ -•�..---�.:.-.�,. [j [] Delta Type of.Casing U Irrigation Approx. . Eastern Cathodic Protection Depth Specifications a ;`1' ? Geophysical Depth of Grout Seal Other Type of'-Grout` `3 J Surface"Seal Installed by s Repair Work Done ❑ Type of Pump H.P. State Work DoneR Well Destruction ❑ Well Diameter Sealing Material (top 501) ) Depth Filler Material (Below 501) I t tt TYPE OF SEPTIC WORK; NEW INSTALLATION U REPAIR/.ADOITdDN_ - o septic tank or, seepage'pit permitted if public sewer is c , a i "available within 200 feet.) Installation will serve: esidence L--�Commercia7` _ Other 3 ) Number of living units: Number of bedrooms Lot size ! it � { Character of soil to a depth of 3 feet: �5 1 j Water table depth y " SEPTIC TANK Type/Mfg I Capacity ~y No. Compartments �+ PKG. TREATMENT PLT. ❑ Type/mfg Capacity .Method of Disposal =s SEWAGE SYSTEMDistance to nearest: Well""-""--Fouridatidnt Property Line r DESTRUCTION ; LEACHING LINE No. & Length of lines � �—�-� Total length/size Jt- i . FILTER BED Distance to nearest: Well Foundation i Property Line I SEEPAGE PITS Cj Depth Size Number - SUMPS E:T-� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have;prepared,this application and that the work will be.done,.in ty accordance with San Joaquin coun ordinances, state laws, and rules and'regulatiofs of the•SaH Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that inithe performance of the work for which this Permit is issued, I shall not employ any person in.such.manner as to become subject to. compensation laws of California." ntractor's hiring or sub-contracting sigr5aturecert Pies the-following: "I certify that in the performance of the work for which t ermit is issue 1 shall ploy persons subject to workman's compensation laws of California." . �! The apply t st call f all quire ins ections. Comphete d awing on re ers '! Signe etw Title: r , Date: FOR D E_NT U_SE{ONLY _ Application Accepted by i Area ) ;S k X466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date - 0 Manteca 823-7104 , Final Inspection by Date ( �Z ti-$3 L7 Tracy 835-6385 Applicant -' Return all copies to: Environmental Health Permit/Services 1601 E.wHazelton Ave., P.O. Box 2009, Stk., CA 95201 l ^--^--•FEE•---•-BASE--—AMOUNT"DUE--" AMOUNT-REMITTED' —RECEIVED-13 — 'DATE'-- °' 'PERMIT'NO.' INFO EH 13-24 REV. 10/82 r 14-26 `-A' ��/82 500