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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.. Telephone (209) 466-6781 DATE ISSUED Q o2 -PERMIT EXPIRES 1 YEAR FROM 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 described. This application is made in compliance with San Joaquin County Ordinance No. 544 for sewage or No. 1862 for well/pump 1 and the Rules an R ulati ns of the San Jo quin Local Health District. 1 Job Address - Z, Subdivision Name Owner's Name --�M \&)'I �W 1C, Address �� d U �l� T�"U Phone Contractor's :came j EF wp`l��fiJ License No. S I l� ��— _- Phone TYPE OF WELL/PUMP WORK: NEW WELL I--i WELL REPLACEMENT DESTRUCTION❑ ! PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 l _DISTANCE TO-NEAREST-SEPTI C-TANK" `SEWER'LINES'-- DISPOSAL'TLIJ —PROP:—LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I " (_] Industrial U Open Bottom Ll manteca Dia, of Well Excavation I i L] Domestic/Private r Gravel Pack Tracy Dia. of Well Casing �]Public ' D Dther l�J Delto Type-of-Casing V Irrigation _ _ Approx- Eastern Depth � Specifications Cathodic Protection P Depth of Grout Seal F-.Geophysical _ _ - Type of Grout Other f Surface Sea'1 Installed by Repair Work Donej Type of Pump H.P. Stale Work Done Well Destruction [_ J Well Diamettcr Sealing Material (top 50') { Depth E �T Filler Material (below 509 1 +t]t][�t][7g4�S7.7r�9[E]t3X3Elt' - TYPE OF SEPTIC WORK: NEW INSTALLATION-I J_REPA•IR/AODITION (No septic tank or seepage pit permitted if public sewer is Installation will terve: Residence )( Commercia',"/- E available within 200 feet,) Number of living units: �— Number of bedrooms -`Q�-- Lot size 7300 Character of soil to a depth of 3 feet: '? Water table depth SEPTIC TANK LJt Type/Mfg --Capacity--_ No. Compartments PKG. TREATMENT PLT, [], Type/Mfg Capacity Method of Disposal ♦ j Distance to nearest: Well d oundlaation Property Line LEACHING LINE j , No._A_Length,of lines Total length/size C-) F FILTER BED Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ` Depth a _ j Size 3 Number _ �~ SUMPS �01 stance'to'neares t:: Well Foundation Property Line DISPOSAL PONDS [-1 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 t 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,ti shall employ persons-subject to workman's compensation laws of California." lica t must Cal for all r ired i pections. Complete dr ing o erse side.Ir 5 _ Title. (� °�. ,_ Date: ~ F DEPART] T USE ONLY i Application Accepted by Area Stk 466-6781 �. Additional Comments �!/.//N �oifi(�c r,p �i1v /e. Zy [ X. (] Lodi 369-3621 j Pit or Grout Insp ction b ___.4A te [) Manteca 823-7104 J Final Inspection by e ' ¢ {' Date Z # E] Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16CI E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 ` 10/B2 500 i 14-26 . . J