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y� � � .�'• -.k Vis. x �=. .� �i P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r y 1601 E. HAZELTON AVE., STOCKTON., CA PERMIT NO. 11 Telephone (209) 466-6781 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 Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressSubdivision Name Owner's Name '//4#' P.eRirKS Address � g Z ,*�} Phone 114.2 '614' Contractor's Name - -,$"e�/„*x License No. ;.5 /_�.f Phone 1,07 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE t k TYPE OF WELL `PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private —E]-Gravel-Pack- Q Tracy Die—of461,1-Gas-ing Public F-1 Other , Delta ' irrigation Type of Casing , U g t `a..J'Approx. �] Eastern De th ' Specifications Cathodic Protection p Depth of Grout Seal � Geophysical R, Other ""..Type-of Grout 17 i Surface Seal Installed by Repair Work Done ❑ Type of Pump_ H,-P: '-State Work Done Well Destruction ❑ Well Diameter =Sealing-Materia l¢top-50'} �. _ Depth r �� Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION �REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer .is t =, available within 200 feet.) Installation will*serve: Residence Commercial Otherj Number of living units: Number of-bedrooms �7— Lot size -17 X!Ple i 1 Character of soil to a depth of 3-feet: _ [;/ y► Water table depth , �. . SEPTIC TANK w rt- .«,_Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg � "� Capacity Method of Disposal SEWAGE SYSTEM Distance-ro nearest Well A& Foundatipn d Property Line DESTRUCTION :-.. (Q LEACHING LINE No. & Length of lines ,Z A2!0 Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size �'3 1 Number / SUMPS lJ Distance to nearest: Well �` Foundation 1 �t Property Line c j DISPOSAL PONDS [� I�mm .II Y�YII�9IP��YYYrYIYI� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county i 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 emplpy persons subject to_workman-'srcompensation laws of California." The applica"ust call for allure uir d inspections. Complete drawing onsreverse side. Signed X �, Title: _ Date: EPARTMT U5 O ENNLY Application Accepted by Area Stk 466-6781 Additional Comments: (.f Lodi 369-3621 Pit or Grout Inspection by Date 3— Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all COPA. :—in -Hazelton Ave=, P-.-D7-Box-2009—Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED ' '-" RECEIVED'BY'"- `DATE ry` XPERMIT N0. INFO 4 0 t --3f-8 IS LI-cl EH 13-24 REV. 10/82 10/82 500 14-26 fol—