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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 23-q"_L�5- Telephone (209) 466-6781 DATE ISSUEfl, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the 11 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 '9 Ap/y 8 el " Xl Subdivision Name Owner's Name /fJe yam/ fJ} Address may/ ./J-Qg�-ega77 F! A-wy Phone Contractor's Name License No. /66 -S8G Phone S'�3-y.Z/07 O� W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION 1 PUMP INSTALLATION [] SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r _ DISPOSAL FLD. PROP. LINE f FOUNDATION �1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 I Industrial 4 � ❑ Open Bottom E]Manteca Dia. of Well Excavation 11Domestic/Private Gravie l Pack Tracy Dia, of Well Casing Public F-1 Other El Delta -� irrigation -Type of Casing g Approx. ❑ Eastern Specifications Cathodic Protection :Depth p Geophysical Depth of Grout Seal ❑(Other Type of Grout ( _ , Surface Seal Installed by Repair Work Done ❑ Type of Pump., ' H.P. State Work Done Well Destruction U Well Diameter_: Sealing Material (top 501) Depth Filler Material (Below 501) N TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is ' Installation will serve: Residenavailable within 200 feet.) ce X Commercial _ Other Number of living units: A Number of bedrooms 1/ 'Lot size / A e r e Character of soil to a depth of 3 feet: : CZ &AA1 Water table depth Y` .SEPTIC TANK © Type/Mfg Ave- CAST Capacity 1601V No. Compartments ;;t PKG. TREATMENT PLT. ❑ Type/Mfg Capacity y� Method of Disposal _ Distance to nearest: Well ✓~d Foundation ;a o Property Line 30 LEACHING LINE ❑ No. & Le6gth of lines Total length/size FILTER BED ' Distanceto nearest: Well ICO d Found ti n ��' ® y a o Property Line SEEPAGE PITS Depth 't size Number SUMPS IJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS - I hereby certify that I have prepared this application and that the work will be done in accordance.with San Joaquin county i 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 t 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 m st call for all required inspections. Complete drawingfon reverse side. E Signed X Title: �' Date. -I"-.Z .6--*3 k OR P ENT USE ONLY Application Accepted by Area /� EJ Stk 466-6781 Rdditional Comments: [1 Lodi 369-3621 Pit�or Grout Inspection by Date 0 Manteca 823-1104 Final Inspection by Date.�3 40' 0 Tracy 835-6385 Applicant - Return all copies to: ',Environm Health Permit/Services 1601 E. .Hazelton Ave., P.O. Box 2009, StkV CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO B'5-LiSS EH 13-24 REV. 10/82 10/82 500 14-26 ,_� -yam