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APPLiCATIONjFDR PERMIT 'r SAN JOAQUiN LOCAL. HE4LTH ,DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -Telephone (209) 466-b781" DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in-Triplicate) r 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 l ao 5Pf R- ,p subdivision Name Owner's Name -[Q C pvR.A p Address rte,/ J F �,FS�f-f Phone ?_I'll V/12 Contractor's Name /y %;;L L,r�2 License No. 3 ��' 15" Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ I 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK' / > SEWER LINES A DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public , 11 ❑ Other s ❑ Delta Type of Casing Irrigation I—i ig Approx. ❑ Eastern Specifications r I ❑Cathodic Protection f , Depth Depth of Grout Seal ❑Gegphysical Type of Grout ❑OthLr (�{ Surface Seal Installed by _ 1 Repair Work Done ❑ Type of, Pump's= ' h.P. State Work Done --� Well Oestruction U Well Diameter; -Sealing Material'(top 50') _ v + Depth Filler Material (Below .50') TYPE OF SEPTIC WORK: NEW INSTALLATI6N ❑ REPAIR/ADDITION (No septic_tank or seepage-pit permitted if public sewer is [, available within 200,feet,) Q r Installation will serve: .ResJd4Tce. nim ercia1 Other,. Number of living units: Number,of bedr66'mss�_'- - Loth size X VD1 Character of soil to a depth of 3 feet =$A"!yy J�r l�;at . Water table depth el SEPTIC TANK Type/Mfg l. !' Capacity /:2Q-o dAZ No. Compartments x � r PKG. TREATMENT PLT. Type/Mfg ' i Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest:_jWe11 Foundation JA -Property Line 30,'7- DESTRUCTION 3D,'7-DESTRUCTION I." LEACHING LINE ❑I No. &^L16ngth of lih-e"s Total length/_-siaeyk FILTER BED ❑ Distance';to nearest: WeJ-1 Foundation°`-Z,�� 4,-Property Line - 41, SEEPAGE PITS ❑ Depth t Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line tt DISPOSAL PONDS ❑ sx -0 I hereby certify that I have prepay red this application and that the work will be done iR accordance with-San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent'sisignature 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.workmant compensation laws of California;" f2' Contractor's hiring or sub-contracting signature certifies the"f6llowing: "I certify that in`-the performance of the work forwhich this permit is issued, I shalliemploy persons subject to workman's compensation laws of California."'= ' 't The applicant must call f a quired inspections. Complete drawing on reverse side. f Signed X , Title:_ a Date: " PARTMENT 111 1111 Application Accepted by Gvr2- Area ❑ Stk 466-6781 Additional Comments: v ❑ Lodi 369-3621 Pit or Grout Inspection.by Dateantena 823-7104 Final Inspection by /1GVI/\ Date 3 ❑ Tracy 835-6385 Applic t`'= Return all copies to: Environmental Health Permit�,Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA�95201 : FEE BRSE AMOI DUE FRMOUNT REMI77ED " RECEIVED BYR' -DATE-' `PERMIT N0. f - INFO4 II 1 10/82 500 I EH 13-24 REV. 10/82 14-26 a,