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f " { APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.., STOCKTON, CAq PERMIT N0. Tei.epho4ne..(.2'09')-"466 X6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUEDy (Complete in Triplicate) Application is hereby made to the San,Joaqui'n Local Health District for a permit to construct and/or install the work herein ! descr#bed. 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 f t n J uin,Local Health Di_strict., Job Address dEr3.] 1�V/ Subdivision Name 4/ Owner's Name d Address ` y- Phone _ 191 Contractor's Name { License No. Phone TYPE OFWEL f/,PUMp,�.SJOR;: - NEW WELL WELL REPLACEMENT. Q DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ` U t OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER'wLINSf 4 f ; F j ,a -�DI5P05AL'FLDr�».-. .� "PROP,' LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } I Industrial � U Open Bottom [] Manteca Dia. of Well Excavation w LI Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other Del to L IrrigationType of Casing i Approx. � Eastern f Cathodic Protection i Depth Specifications Depth of Grout Seal Geophysical - U Other ;; Type of Grout Surface Seal Installed by Repair Work Done Type of Pump " "�- "- '" H p State.Work Done : s� Well Destruction U Well Diameter Sealing;Material (top 501) , Depth + Filier Material (Below 501) ,) TYPE OF SEPTIC WORK: NEW•INSTALLATIONREPAIR/ADDITION 'semse' f � U �j (-No pc tank or seepage pit permitted i'f�public sewer is _y a y � available within 200 feet.) Installation will serve: Residenc,5'e Commercijall Other j r.,a Number of living units: _,___.[Number of bedroom i . Lot' ize .,Character of soil to a depth of 3 feet: 1 — ."1. Water table depth 70 SEPTIC TANK -Type/Mfg —" Capacity.l1,0� No. Compartments Z f PKG.,TREATMENT PLT. U Type/M1 7. 4 Capacity ----� _ Method of Disposal F� SEWAGE SYSTEM Di,stanceTto nearest: Weld- Foundationv�_ Property Line M (pb DESTRUCTION ; LEACHING LINE No. '& Length of lines Total length/size (J Q a X FILTER BED Distance to nearest: Well r� Foundation 4- Property Line 40.'4— P L� SEEPAGE PITS Depthf`�5.� Size rl %r Number SUMPS �� Distance to nearest: Welle�Foundatior ;Property Line �_.�. - ' 015P05AL PONDS C� I' s ,y I hereby certify that I have prepared this application and that the work will be done in Lar cordance with San Joaquin county r ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distriot. 11-11 N(,i•r" Home owner agent"s signature certifies the following: "I certify that in the performance of therwork for which this" permit issued, I sha not employ any er5on in manner as to become subject to"wbrkmarn� compensatlion°laws of Ca1ifor4ja." Cont ctor's hiring ors -contracting re ert" ies the following: "I 'certify that in the performance of the work for which thi permit is i sued, hall plo s bj to war ompensation laws of California." e The pplicant st for i r ns. Co ete dr on r e side r Signe X A^ tle: i Date: //—jZp,,�(�� FYPARTMENT USE ONL Application Accepted by Area 1! _ •ai Stk C66-6781 Additional Comments: ' [] Lodi 369-3621 Pit or Grout Inspection by Date C�149&z II&J �hanteca $23-7104 Final Inspection by " Date �` T;rac ..835 6385 w y f r Applicant - Return all copies to: Envircrmer'6&i--Health Permit/Services 1'd1 E. HaYelton Ave., P.O.rBcx. 2009,,Stk., CA 95201' FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 j 1 y