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APPLICATION FOR PERMIT J `Lry SAN JOAQUIN LOCAL HEALTH DISTRICT ll FF } 1 V 3 .. W i� i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 Q TE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SANS J�?1�.QU,iLO%F� _ l �( ' ..r�:.._LDS./E 7YL_c24 (Complete in Triplicate) HEALTH DISTRICT 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 Ordinance No. 549 for sewage or No. 1862 for well/pump 1 and the Rules and Regulations of the San Joaquin Local Health District. i Jab Address ko — M �k)iU . .ACW?C" . Subdivision Name Owner's Name Address I 1117Y 0 S - 6 A f an L T n/ Phone _2-4(, 3 Contractor's Name JSega Al License No, Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS \ ' F] Industrial U Open Bottom Manteca Dia, of Well Excavation Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing C Public Other Q Delta Type of Casing Ljirrigation Approx. E] Eastern Depth Specifications Cathodic Protection Depth of Grout Seal h 1-1 Geophysical C Type of Grout Other Surface Seal Installed by Repair Work Done ® Type of Pump �_ H.P' State Work Done 1 \,� Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') n TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LJ (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 q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION Q LEACHING LINE ❑ No. & Length of lines '- Total-length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS U 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 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 Taws 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 applican mu t 11 fartions. Complete drawing on reverse side, { Date: v�k� 93 al d inspec Signed X Title: wor F R DEPA TMENT USE ONLY Application Accepted by �/ �_� _ Area Q O Stk 466-6761 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date anteca 823-7104 Final Inspection by r Date ❑ Tracy 835-6385 Applicant - Return all copies o: . vironmental Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk., CA 95201. =INFO — EH AMOUNT DUE _ AMOUNT REMITTED RECEIVED BY 1` DATE PERMIT NO. 13-24 REV. 10/82 10/82 500 14-26 �SLp 9