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APPLICATION,FOR PERMIT l � 1903 SAN' JOAQUIN LOCAL HEALTH-DISTRICT 1601 E. HAZELTON AVE., STOCKTON., CA PERMIT N0. 3-1 0 LCCAL Telephone (209) 466-6781 + i- PERMIT ExPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) 1 Application is hereby made to the 5an '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 and the Rules and Regulations of the San,Joaquin Local Health District. Job Address / )f y1 C —,eL=r�� 6 . I Subdivision Name Owner's Name AAL, G. �, Address f Q Q Phone Contractor's Name s,� �_SO.z,J License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT r.. DESTRUCTION � W PUMP INSTALLATION SYSTEM REPAIR OTHER p_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL p, PRDP. 'L1NF 0i FOUNDATION' it AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C 1 Industrial Open rnw� t U p I� ❑ Manteca Dia. of Well Excavation / Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing /� ' Public � Other � Delta irrigation Type of Casing L i 9 Approx. Eastern Specifications ❑ Cathodic Protection Depth P Geophysical r, Depth of Grout Seal ❑Other r Type of Grout I Surface Seal Installed by Repair Work Done Z Type of Pump --- H.P. State Work Done (f AL Q L1,61 (_ Well Destruction ❑ Well DiameterI Sealing Material (top 501) Depth Filler Material (Below 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [J (No septic tank or seepage pit permitted if public sewer is p iI available within 200 feet.) Installation will serve: Residence _ Commercial Other �tJ Number of living units: Number of bedrooms Lot size Character of soil to a depth of3+feet: Water table depth SEPTIC TANK T { C! Type/Mfg 9i� Capacity Na. Compartments PKG. TREATMENT PLT. Type/Mfg ;I Capacity Method of Disposal SEWAGE SYSTEMDistance �to nearest: Well Property Line DESTRUCTION ❑ Foundation j1 LEACHING LINE ❑ No.- & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth !I Size Number SUMPS lJ Distance rto nearest: Well Foundation Property Line i 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 laws 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 applica ust call for 11 re fired r. inspections. Complete draw' g on reverse side. C� Signed x 67 ETitle: Date: / — NT U LY Application Accepted b - Area _L� E] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by 1 Date — Manteca 823-7104 Final Inspection by 1 Date 'LU 3 L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT DUE# AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Eh 13-24 REV. 10/82 [ { 10/82 SOO 14-26 �j