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APPLICATION FOR PERMIT c SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. " ro 3� Telephone (209) 466-6781 HATE ISSUED PERMIT EXPIRES 1 YEAR FROM GATE 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 egulations of theSan Joaquin Local Health District. Job Address (�L l a$fIN R.O A-lb Subdivision Name Owner's Name 1XW16Mj VtO,G101A 2 ddress Z(0 v asr-0 M'�'[,f} Phone Contractor's Name L' 1.#tQ�L.WELL,6'U ? License No. 7ill<(o0 Phone A qb4 W TYPE OF WELL/PUMP WbRK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONS , 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES : SEPTIC TANK SEWER LINES 7S' DISPOSAL4FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �A�I Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing G Public �p7 Other DeltaL (�� 4� ❑ ype of Casing d G . T Irrigation Approx. "`❑.Easten- ❑ Cathodic Protection Depth 3 Specifications '--Depth-of Grout Seal 5-0I' Geophysical Type of Grout _ OVIE r GR ILLT Other c Surface Seal Installed by ci*w Repair Work Done ❑ Type of Pump S H.P. State Work Done SPITlk L U Well Destruction _ W.e_ll._.D_ia.mete -r. _50') C-01SeliMaterial (t Depth .'r Filler Material• (8elow '50') - R� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE6AIR/ADDI?IONS''❑ (Noseptictank or seepage pit permitted ;if,public sewer;is available within 200 feet.) Installation will serve: Residence _ Commercial _Qthef• Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: � _ r=�._,_. �- Water table depth SEPTIC TANK EDiType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity ?, Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well `Foundation Property Line T-- DESTRUCTION J LEACHING LINE ❑ No. & Length of lines Total length/size'. -- ,-, FILTER BED Distance to near st: Well Foundation Property Line , SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: WellFoundatauri; Property Line DISPOSAL PONDS ❑ +k I hereby certify that I have prepared this application and that the work will bit-donN 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 workmanh compensation laws of California." Contractor's hiring or sub-contracting certify that in the performan4e of the work for which this permit is issued, I shall employ p4r-sons subject to workman's compensation laws of California." The applicant m all for all egwi�ed inspections. Compl'ete draw' g o rev ide. Signed X Jwon Title: U Date: .. _s DEPARTMF.N� SE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date _ 3 ❑ Tracy 835-6385 �! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 30 EH 13-24 REV. 10/82 "" "A1 ,/~ ' -34c/72 500 14-26 U fin! C �I