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e. " F r � APPLICATION FOR PERMIT �} p SAN JOAQUIN LOCAL HEALTH DISTRICT -_ `J a �Y k 1601 E. HA7ELTON AVE.,STOCKTON,` CA PERMIT lV . 0,3--2 k Telephone (209) 466-6781 DATE ISSUED J PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED s , J (Complete in Triplicate)' o { 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 Or inance No. 549 for sewage or No. 1862 for well/pump and the Rules.a d egula ions of the San Joaquin Local Health District. 4 I Job Address � l 1 ,CAI ,C .t1 bdivision Name'/� 7,536 N` Lijgh Owner's Name Address �p ^��/ Phone ^' Contractor's Name0 icense No. Phone -O TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION � SYSTEM REPAIR [� OTHER U ` DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE rl' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -�- AREA "'CONSTRUCTION'SPECTF1t ATTONS """LL'" INTENDED-rUSE- " —TYPE-OF'WELU" PROBLEM A / ti Industrial pen Bottom Manteca Dia. of Well Excavation ii U Domestic/Private F-1 Gravel Pack ❑Tracy � Dia. of Well Casing i Public ❑ Other ❑ Delta F Type of Casing n t E - rri ationApprox. Eastern \ 9 ❑ Specifications - , ❑ Cathodic Protection Depth Depth of Grout Seal t/' 4 ❑Geophysical Type of Grout ❑Other Surface Seal Installed by "r'r " Repair Work Done ❑ H.P. State'Work-Done Type of Pump �(�{� ' Well Destruction U Well DiameterSealing Material (top 50r)— Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ (No se 1 c tank or seepage pit permitted if public sewer is available within 200 feet.} r1 � Installation will serve: Residence _ Commercial � Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of3 feet: ' water table depth �« Cit No. Compartments SEPTIC TANK ❑ aacType/Mfg p y PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ^ SEWAGE SYSTEM 1-m Distance to nearest: Well Foundation - Property Line (J1 DESTRUCTION �-J LEACHING LINE [J No. & Length of lines -Total length/size Property Line FILTER BED � Distance to nearest: Well Foundation~ + Pro P -.w -.r--. ....�- - - •• -Number SEEPAGE PITS Ej Depth Size SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS [I `v [ the work will be done in accordance wSth 5a'n "Joaquin county" hereby certify that I have prepared this application and that r 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." _ Contractor's hiring or sub-conteact.ing signature certifies the-following:""'I certify that in the performance of the work for which this permit is issued, I shall employ ersons subject-to workman's compensation laws of California." The applicanrmucall for all re i ed i spections. Completed w ng on -reverse side. ' Signed K �iM tlDate:FOR DEPAT, SE ONLYStk 466-6781 �Ap cati n Accepted by 7- Area e- X N Lodi 369-3621 - per + Additional Comments: Pit or Grout Inspection by Date L-1 Manteca 823-7104 ti &Enmi -— tes Tracy 835-6385Applicantr,Returnra.L copjes�" ronmental al�thPr.,t/Services 16 1 �. Hazelton AveP.C. Box 2009, Stk., CA 95201 4 F. FEE ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. INFO k y <Z 10/82 500 EH 13-24 REV. 10/82 "F 14-26 '�