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I APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT 110, Telephone.(209) 466-6781 DATE ISSUED T 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 Address o2a7 143' D $rX,✓ Subdivision Name Owner's Name ul XLc,Ea/ZjA4,q,J Address E ,5i4rr! Phone Contractor's Name F4Zye a, INGpD License No. Lzs'Z7G Phone .Sly 347/ ._- TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION❑ ' PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER [D f p6 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial ❑Open Bottom F� Manteca Dia. of Well Excavation r Domestic/Private [] Gravel Pack ❑ Tracy Dia. of Well Casing ll Public 1-1 Other E] Delta Type of Casing U irrigation Approx. [] Eastern � CDepthw.� Specifications Cathodic Protection .DelZ1r& Grout Seal Geophysical l' �. 11 f ❑Other 4 tr 4'.) , . -� Type;of Grout 4 ' urface.,Seal Installed by Repair Work Done, Type of Pump H.P. ' State_ Work Done Well Destruction U Well Diameter Sealing Material, (top 50') Depth Filler Material .(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LV' (No septic tank or seepage pit permitted if public sewer is available within 200.feet.) 9} Installation will serve: Residence omnercial, Other o�3 Number of living units: T Number of bedrooms *T2,*s Lot size Character of soil to a depth of 3 feet: L,¢y Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg ' Capacity Method of Disposal Distance to nearest: Well Foundation 4 '`t' Property Line LEACHING LINE Fir No. & Length of lines / -- /Q Total length/size FILTER BED. Distance to nearest: Well Fou da`tion 30 f Property Line 3•06F SEE-P*E PITS EK Depth "* ; Size 33 Number SUMPS [_J Distance to nearest: 'Well' Foundation 7& Property Line _4W. SOS DISPOSAL PONDS �} I hereby certify that I have prepared this application and that the woeit 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 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 employ persons subject to workman's compensation laws of California.," G The applicant must call for all required i pec tions. Complete drawing on reverse side. Signed X Title: �..-,rs , Date: neF OR DEPARTMENT USE ONLY .� i Application Accepted b8J(kea AX Area E] Stk 466-6781 Additional Comments: (;,Vc- iv&, t Lodi 369-362.1 Pit or Grout Inspection by Date !i C —� Manteca 823-7104 Final Inspection by - Date Tracy 835-6385 Applicant - Return all copi o: Environmental Health Permit/Service 601 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 10/82 500 14-26