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APPLICATION. FCR PERMIT SAN .OAQUiN LOCAL HEALTH DISTRICT Q �} 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. O O` Telephone (209) 466-6781p 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 4 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 t e San Jo quinyLocal Health District. Job Address df i � Subdivision Name 4k2Y Owner's Name r a � Address Phone 513/5714 ;77 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, tINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE)OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public Other Delta�J ❑ Type of Casing V Irrigation l.Approx. ❑ Eastern Specifications Cathodic Protection Depth F-1CathodicDepth of Grout Seal { ❑Geophysical Type of Grout ❑Other Surface Seal Installed,by . Repair Work Dane ❑ Type of Pump: h.P. State Work Done r <,' Well Destruction ❑ Well Diameter Sealing'Material (top 50') —.--� 1i1i f � i Depth "�"� y°'"""' �' "Filler Material (Below 50") TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDhT10N [NK(No septic tank or seepage pit permitted if public sewer is ti,r t available wi-thin 200 feet.) Installation will serve: Residence +-*"' Commercial _ Other Number of living units: I Number of bedrooms 3 Lot size U X Character of soil to a depth of 3 feet: .Co Water table depth 161t-2 SEPTIC TANK YQ Type/Mfg w C V.% Capacity I ZQ o No. Compartments �. PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well /(�70 Foundation _ Property Line -DESTRUCTION 1 - zt . LEACHING LINE Fr No. &Length of lines Total length/size t .t1 FILTER BED ❑ ;{Distance to nearest: "Well Foundation Property Line SEEPAGE PITS `rDepth l.[ $;,Size; 7j 3 �! _ Number SUMPS ❑ Distance to nearest: .i Well Foundation Property Line DISPOSAL PONDS ❑ 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 Taws of California." { Contractor's hiring or sub-contracting signature certifies the following: 1 certify that in the performance of the work for which i this permit is issued, I shall employ persons subject to workman's compensation laws of California." i The applicant must call for all r qui �d ins ections. Complete drawing on reverse side. / ¢ Signed X Title: 11162i Date: (UL Q. 1 R �ARTM T USE ONLY Application Accepted by Area c1 Z Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date $ ❑ Manteca 823-7104 Y Final Inspection by ti - Date � —9-7 ❑ Tracy 835-6385 y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i�n i F FEE BASE AMOUNT DUE AMOUNT REMITTLO RECEIVED BY DATE PERMIT NO. i INFO 3 2>— to / �q U 1p A EH 13-24 REV. 10/82 t 1/0/,82 500(- .4 14-26 �/�.� n_ yn��JVYA 7 � } 3Z