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APPLICATION FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �3^ PSdkVQ 1601 E. HAZEL-TON AVE.,,STOCKTON, CA PERMIT NO. ?3 Telephone (209)'.466-6781 l ` DATE ISSUED 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 Ordin nce No. 549 for sewage or No. 1862 for well/pump C4 0Q and the Rules and Regulations of /the''Saa!n Joaquin Local health District. Job Address S��n �� C l.{ 1✓fe. _ _ Subdivision Name S n l 1 Owner's Name Jar"e4 v'k!A Address 3s Phone Awa QQ'7 Contractor's-Name License No. Phone -� r i TYPE OF'JELL/PUMP WORK: ti� NEW WELL to WELL REPLACEMENT DESTRUCTION ❑ C� .. y PUMP'INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST:'SEPTIC TANK /nfj°4. SEWER LINES lio0 + DISPOSAL FLO. t:)C) (PROP. LINE /Q FOUNDATION f;., '� AGRICULTURE WELL OTHER WELL __jegL PITS/SUMPS 'INTENDED .USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 !J Industri-al"_ U Open Bottom Manteca Dia. of Well Excavation Lv 6omestic/Private Gravel Pack L Tracy Dia. of Well Casing (] Public l ti EjOther ©eelta Type of Casing Irrigation ; '�� — ��pprox. � � Eastern Specifications �� ' Cathodic`Protection Depth '. Depth of Grout Seal Q LjGeo physical3 1 Type of Grout U Other ........-`I "� t / Surface Seal Installed by 4, r/ Repair Work Done L Type of Pum p S YV H.P.H.P• t State Work Done Well Destruction L Well Diameter r Sealing Material (top 501) Depth i Filler Material (Below 501) TYPE OF SEPTIC WORK: NEWLIIJSTALLATION a REPAIR/,ADDITION D (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other r' Number of living units:r" Number of bedrooms Lot size Character of"soil to a depth of 3 feet: Water table depth SEPTIC TANK U Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. U Type/Mfg Capacity t Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE u No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property..Line .=--tea-- SEEPAGE PITS Depth Size Number SUMPS Lj Distance to nearest: Well Foundation � • .Proper y Line DISPOSAL PONDS L t I hereby certify that I have prepared this application and that the work 11 i'l1`'b done -in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heal,�h 'District: Home owner or ensed agent's signature certifies the following: "I certify teat in the .performance of the work far which this permit is sued, all not employ any person in uch manner as to become subject to;,00rkman�,compensation'laws of Cal perm Contracto s hiring or sub-contracting ature ifies the following: "I certify that in the performance of the work for—which this perm t is issued, I hall em loy s ct to workman's compensati laws of California." The appli ant 1 for all u' s.' omplete drawing o verse- _ Signed X Title: a Date: r OR EPARTMEN PSE ONLYApplication Accepted by Area,- + -`v , Stk 466-6781 di 369-3621 Additional Comments: _ o Pit or Grout Inspection by . Date r-16 3 LJ Manteca 823-7104 Final Inspection by Date kV- C•l�� L Tracy 835-6385 Applicant - Return all copies tiLa: Environment 1 Heal P mit/ vices 1601 E. azel Ave. P 0. Bax 2009, Stk., CA�95201 r - Q FEE BASE AMOUNT DUE AMOUNT REMITTED R CEIVED BY DATE PERMIT N0. 7"W INFO �3 g� �✓�rasp EH 13-24 REV. 10/82 10/82 500 14-26