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f M APPLICATION FOR PERMIT SAN ,OAQUiN LOCAL HEALTH DISTRICT ��/( 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, I� D7` Telephore {209} 466-6781 I DATE ISSUED " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j , 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 ccmplidnce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/,pump and the Rules and Regulations a Di tri r e Jab Address Ca. r. � U -04 _ _ VMT"r � f s AC3s ubdivision Name Q41Ut' Owner's Name STQCKTON SERVICE CORP. Address P.O. BOX DRA T L Phone Contractor's Name alen Waggoner License No. 263644 Phone (209) 57'7-401 'll rr,, TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION (J-) PUMP INSTALLATION ❑ SYSTEM REPAIR j❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS o INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial- ❑.Open-Bottom= 0 Manteca- . Dia, of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing L:1 Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal ..I ❑ Geophysical Type of Grout �❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter T /lye Sealing Material (top 50') Wj4 Depth Filler Material {Below 501} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑j REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑, Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line II �SftA-F PITS ❑ Depth Size Number SUMPS Cj Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county C 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." C Contractor''s hiring.,&r sub-contracting signature certifies the following: "I certify that in the performance of the work for which r this permit-is issued, I shall employ persons subject to workman's compensation laws of California." The appli must cal fpr all r vire inspections. Complete drawing on reverse side, Signed X Title: PRESIDENT Date: 9-26-83 1 P TENT US LY Application Accepted Area --13 ❑ Stk466-6781 Additional Comments ❑ Lodi 369-3621 Pit or Grout lnspection'by Date >iManteca 623-7104 Final Inspection by Date t'��r`� ❑ Tracy 835-6385 Applicant - Return all cop' o: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, St k., CA 957]. FINFO E BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i 10/82 500 ) EH 13-24 REV, 10182 v— I