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.4 ` APPLICATION FOR,PERMIT, SAN JOAQUi'! LOCAL,.HcALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��-1-L oLo Telephone (209) 466-6781 DATE ISSUED 'y'�11 '�S� PERMIT EXPIRES I YEAR -FROM DATE ISSUED , _ f (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 thhe�Saan�Joaquir,v�Local Healt! .District• Job Address DQ C�oN Subdivision Name �k oY Owner's Name 11:1 �'- `'� dress q 6 f O o hone .= � Contractor's Name 1�:► 1 License No. Y one 3f 3 ! TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE J 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 Other [] Delta Type of Casing Irrigation Approx. Eastern Specifications { Cathodic rotection Depth l Depth of Grout Seal Geoh s 'Cal .. ...., .,.� ..� ,...._ . . ...�.. .. .. { P Y Other # _ fac .S Installed 5urface,Sea1 y Repair Work Done Type of Pump N.P. State Work Done �* We11 .Destru_ction LJ Well Diameter Sealing Material (top 50') �- Depth Filler Material ,(Below 501 7.14 h v I TYPE OF SEPTIC WORK: NEW INSTALLATION [�.I REPAIR/ADDITION FJ (No septic tank or seepage pit permitted if public sewey s +� ,.`IVavailable within 200 feet.) Installation will serve: Residence Commercial Other U{�-5—t � ��' 4-o IIF_ Number oftil_v ng'unitsF"" �Number of''bedroo,4� -Lot,,si_ze�_ 7et - QWa,ter tabl35 ' Character�of soil�td a depth of 3ufeet:. fl S Ca acct Y p - --.}___+.��, ..,y.-. {me - s q SEPTIC TANK Type/Mfg p y l�d L} No Compartments �. +p 4' #k _ PKG. TREATMENT PLT. [J Type/Mfg Capacity + '-► -� •Method of Dis oral SEWAGE SYSTEM Distance to nearest: lJell FoundationPoperty Line 1 DESTRUCTION LEACHING LINE No. & Length of lines 1 o1 1-6 N Total length/size �� # i FILTER BED . Distance to nearest: Well _ Foundation Property Line Z4 0 {d - SEEPAGE PITS [JDepth 'SizeNumber a . ` SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 1 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 workman6 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." # -) f , The applicant must qal for all required inspections, Complete drawing on reverse side. Signed X Title: �'�' - Date: i PARTMENT U E ONLY/ill, ❑ Application Accepted by / rk �� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Lj Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant _ Return all copies to: vironmental Health Permit/Services 1601 E Hazel on Rve•, P.O. Box 2009, Stk., CA 95201 M pp � I FEE BASE AMOU{NT ` DUE f�AMOUNT REMITTED (� RE�CE,IVER BY DATE PERMIT N0. INFO S • 00 -1 O 6 10/82 500 EH 13-24 REV. 10/82 ��c^7,p 14-26