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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA--- PERMIT NO'. o,3—aS �j 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 workherein 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 .�l /V. ��4t 7t7n+�. Subdivision Name Owner's � Name 726.72 ,Kmps Address 457-s _ ." Phone Contractor's, Name License No. :Z.S`�-°3i.S/3 Phone 'y66—962 7 CA TYPE OF WELL%PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑: OTHER DISTANCE TO DE3EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS- INTENDED ITS/SUMPS-INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑'Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation r ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public �I` EJ Other ❑ Delta _ H - , Type of Lasing Irrigation Approx. Eastern " Cathodic Protection Depth Spzcifications MY Depth-of Grout Seal Ll Geophysical + a �h �Other Type of Grout I Ine ~ Surface Seal Installed byRepair Work ❑ Type of Pump H.P. State Work Done ' Well Destruction E.]_ Well Diameter ":Sealing Material (top 501) I Depth -Filler Material (Below 501) —S)` TYPE OF SEPTICWORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit per if public'sewer.is :11 available within<200 feet.) Installation will serve: Residence K Commercial Other Number of living units: _� Number_of..bedrooms, � Lot size / Character Iof soil to a depth of'3 feet: ,4 �� y.*. Water table depth "I6b 019 SEPTIC TANK] X Type/Mfg ' ,.fig _ $crr+I, _ Capacity 17�s No. Compartments " PKG. TREATMENT PLT. ❑ Type/Mfg " Capacity Method. af Disposal Distance" nearest: Well �_ Foundation > Property Line LEACHING LINE No. & Length of lines T 7. es- Total length/size /70 x' Z _ FILTER BED ❑ Distance fornearest: Well .- Foundation _- Property Line SEEPAGE PITS Depth ^ Size "3 Number 2_ SUMPS 1 LJ Distance to nearest: Welles Foundation /Property Line *' DISPOSAL PONDS ❑ I hereby cerl�tify 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 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." The applicant must call for all require - sp tions. Complete drawin on/ everse s e. Signed X . Title: 4�7rnR _ Date: 4V-2-0 '^�3 ' ilp F EPA TMENT USE ONLY ` +' Application Accepted by Area �� Stk 466-6781 { Additional Comments: ❑ Lodi 369-3621 :0 F Pit or Grout Inspection by ' Date j1-7 ❑ Manteca 823-7104 Final,� Inspecttion by Date ❑ Tracy 835-6385 Applicant -aReturn all copies_to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,rCA 95201 FEE BASE AMOUNT DUE AMOU1dT REMITTED "'� RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-2fi i�