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{ APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 3 1'a 1601 E. HAZELTON AVE., STOCKTON, CA "a PERMIT N0. ( 2 Telephone (209)'466-6781 DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED (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 Joaq in County Ordinance No. -549 for sewage or No. 1862 for well/pump and,the Rules and Reg lations of theE San Joaquin Local H A4th trict. Job Address /75 �� w °l 1"MNN1 E vision Name Owner's Name MR /VDI?13LlTt ddress S+N"+r Phone Contractor's Name ) ph CA4411C License No. '4$')! 4 Phone i TYPE OF WELL/PUMP WORK: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER *❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE +f4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE VF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom [] Manteca. Dia. of Well Excavation 1 U Domestic/Private r❑Grave],.Packv0 Tracy_ Dia. of Well Casing ❑ Public E)Other ❑ Delta Type of Casing L Irrigation Approx. ❑Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by -Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') n I TYPE OF SEPTIC WORK: NEW INSTALLATION E:1REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is V available within 200 feet.) —S) Installation will serve: Residence _Y, Cbmmercial __._ Other Number of living units: I Number-of bedrooms � Lot size �_VZ AC W Character of soil to a depth of 3 feet: L oA vh Water table depth Capacity No. Compartments ~' SEPTICITANK,_— F_-1TYPe/-Mfg. ` + PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal , SEWAGE SYSTEM ❑ Distance to nearest: 'Well Foundation Property Line DESTRUCTION got LEACHING LINE No. A Length of lines i U Total length size FILTER BED ❑ Distance to nearest: Well Q4?_ Foundation J$1 Property Line p F 1 SEEPAGE PITS'. F-1 Depth F Size ~`"'""Number, F j SUMPS Ll Distance to nearest: Well Foundation Pro.per-PiLine V �y DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county t ordinances, state laws, and rules•and regulations of.the San Joaquin Local Health District. n Home owner or licensed agent's signature certifies the, following: hat in the performance of the work for which this following: "I certify tanner as to become subject to workman permit is issued, I shall not employ any person inisuch mcompensdtion laws of California." s the-following: "I certify that in the performance of the wdrk for which Contractor's hiring or sub-contracting signature certifie this permit is issued, I shall employ persons subje'c't:;to workman's compensation laws of California." The applican t call for all requir inspecfions. C&4pl`ete drawing reverse side.' Date: signed XLM1� Title: i PARTMEN E ONLY ❑ Stk 466-6781 Application Accepted by Area ❑ Lodi 369-3621 Additional Comments: _ ❑ Manteca 823-7I04 � Pit or Grout Inspection b Date //�� Final Inspection by Date [T Tracy 835-6385 Applicant - Return all copies to: . Enviro�al �KealthPermit/Services 1fiD1,E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 fPERMIT NO. FLINF BASE. AMOUNT , DUE AMOUNT REMITTED RECEIVED BY ,DATE � � 5 A/=V z 10/82 500 EH 13-24 REV. 10/82 14-26