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i r APPLICRTION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6181 DATE ISSUED // PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C p11oA ete 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 Rul ,R latio s o 5 o a ea istrict. �� ,�0)=&Z Subdivision Name Jab Address 9� � oic H14e6 EX 40, F _ I Owner's Name I�IAYM9 7- T0/_a, M Address /5 3 E,JA)JAWr- F:7,p Phone -5 Contractor's Name ia-hg5aq WmR4 ng&y,y License No. _33709 Z Phone-1rj�}'337 TYPE OF WELL/PUMP WORK: NEW WELL X WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION JX SYSTEM REPAIR OTHER U i DISTANCE TO NEAREST: SEPTIC TANK /`Q SEWER LINES /Q® DISPOSAL FLD. 3 PROP. LINE z 3 FOUNDATION AGRICULTURE WELL r OTHER .WELL PITS/SUMPSsj INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .sy� Industrial % Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private F Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta Type of Casing ��L Irrigation �(//�� Lgj g � �y Approx. Eastern Specifications Cathodic Protection �T- Depth Depth of Grout Seale L-I Geophysical Type of Grout _A 45AC& U Other Surface Seal Installed by �jgsip/i/ Gf/ELL /Illy Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS lJ Distance to nearest: Well Foundation Property Line " 'DISPOSAL' PONDS C� '4 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 ust call fo al re fired inspections. Complete d awing o revers�de. Signed x "Title: Date: /Z 4-�3 R RTMLNT U ON Application Accepted by Area 5tk 466-6781 Additional Comments: � Lodi 369-3621 / Pit or Grout Inspection by Date Z,,— j E] Manteca 823-7104 Final Inspection by Date /�~ .//1 ❑ Tracy 835-6385 Applicant - Return all copies to: En nmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 it FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. [NFO y - EH 13-24 REV. 10/82 10/82 500 14-26