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v. APPLICATION FOsc'pEr2M:T 1. t_ PERMIT Na. +l �y SAN IOAQ�iN LOCAL.HEILTH DISTRICT Y 1641 E.,HA7ELT,GN AVE., STOCKTON, CAW - ^ .V `.4 Teleplio �,<(209)r.40-6781 v �r # DATE ]SSUEp:j i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED yt r { (Complete in Triplicate) r ro r +� .t ermitlfo construct-an'd/or install the work herein Application is hereby made to the San Joaquin Laca1 Health District fora p .described. This application is made*in comp Mance with•,san ,3eaquin County Ordinance No. 549 for sewage or No. 1862 for we pump —T! and,the:Rules and Regulations,of the San Joaquin Local Wealth District. a 1Lam. Su6divisaon Name Job Address fid , .; �/.- .Q a �t�y� Phone" F, Address +� Phone Owner's Name �/ '`�- �' T_ C- Contractors Name I � License No. es 3 f WELL� EPLACEMENT ❑ DESTRUCTION ❑ �" NEW WELL TYPE OF WELL/PUMP.W OAK: -�. ❑ OTHER d PUMP�NSTALLATIaN ❑ SYSTEM`REPAIR ❑ U pROP._LINE SEWER LINES _ DISPOSAL FLO, - `�- DISTANCE TO NEAREST: EPTIC TANS�� - -- OTHEfZ"WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL - `` PROBLEM AREA � CONSTRUCTION SPECIFICATIONS " INTENDED USE TY?EWELD ___--� E -- O en Bottom ❑Manteca Dia. of Well 'Excavation Industrial s U p pia. of Well Casing U.Dome tiic)Private ❑Gravel Pack ❑Tracy - :.. Q Delta Type of Casing �S ' ❑ Public E] Other - �. al" A rox:`, Eastern. ,Spec Irrigation ep ifications ( _ epth,�. - Depth of Grout Seal ❑ Cathodic Protection Type of Grout ❑"Geophysi cal` r Other Surface Seal Installed by H P State''Work Done Repair,,Work gone'❑ Type of Pump' �� sealing Material (top 50') Well,-Destruction ❑ Well _Diameter- — Filler Material (Below 50') Depth::, a.a._ ` e, it permitted if public sewer is - REPAIR/ADDITION ❑ (No septic - - _ tank or see p TYPE OF'SEPTIC WORK: NEW .INSTALLATION.U_! - a'vail'able within 200_feet.) 4.. - 'a 11-1 Commercial Other ; i r_+Installationawill serve: Residence , Lot size2y S/ Number of livisr!g units: / Number of hedrooms_ _Z_,_� Water table depth Character of soil•.to a depth of 3 feet: `;� Capacityx J No. Compartments Type/Mfg } „„SEPTIC TANK l g . ' Capa'ity _-_�� Method:of Disposal pKG. TREATMENT PLT. ❑ Ty Pe/.Mf9_ Foundations Property Line SEWAGE SYSTEM Distance to nearest: Well /,42 . ` DESTRUCTION ❑ i '� � ' f' - i,-n th ' Ines �- 1 `~` Total length size LEACHING LINEr a No. � -+ g -b� -- s C. Property Line f F1LT•ER BFO`A ❑ Distarce to nearest:Wel l a Found-aT1"6rn...— Number SEEPAGE PITS ❑! Depth ` Size- =_ --•—�' , Li earest: Well ne SUMPS �� Distance to nF, U 1 oundation K.. Property DISPOSAL PONDS ❑ ill I 1 hereby certify that sI haveand prepared thisreguapplicationons of an that h tthenwork w HeabthdDistricte in Ccordance with San Joaquin county or which this ordinances, state laws, Home owner or licensed agent's signature certifies the fmannernas to becomeysublectthat ntohworrkman� compensate performance of lionwlawsork fof California."i permit is issued, I shall not employ any p g._ y p +� Goittractor s�hiring or-sub-contract�ing�sigosubj ect�toeworkman�sacompensationrlaws of California." the-thewhit this permit is issued, I shall employ persons' The applicant-must callall required inspections. Complete drawreverse side. Date: ing o 7dby Title:_Signed XFD ARTMENT USE ONL Area Stk369-3621 Application Accep �i.Lodi rAitional Comments: Date ❑ Manteca 823-7104 or Grout Inspection by pate ❑ Tracy B35-6385 Y Final Ins ection by Haze to e., P.D. Box 2009, St k., CA 95201 rr .,!�. . Applicant - Return all copies to: Environmental He th,APermit/services 1601 AMOUNT REMITTED RECEIVED BY DATE �� PERMIT ND. ! r BASE AMOUNT DUE �/ ��FO ' 10/82 500 - a EH 13-24 REV. 10/82 14-26