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APPLICATION FOR PERMIT ` SAN JOAQUiN LOCAL HEALTH DISTRIC j]� iii..�� 888888 YYY !I 1601 E. HAZELTON AVE., STOCKTON, �r A p IT N0. �9 5 i Telephone (209) 466-6781 AUG G 2 9 198 3 DATE ISSUED Fs1 FT,3 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I LOCAL @ (Complete in Triplicate) AN JOA Q --��-pp �+ � 6TNucPd/b 1GTtall the work herein Application is hereby made to the San Joaquin Local Hea th District fora pOrdi V described, This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump I and the Rules a/^nd.Regulations of the San Jjquin Local Health District. Job Address z �u L Subdivision NameJ� r Phone Ad ress GO Owner's NamePhone ':� � "J• License No. Contractor's Name TYPE OF WELL/PUMP WORK: I! NEW WELL 1:1 TYPE REPLACEMENT ❑ DESTRUCTION ❑ .��63C6s�9d1 f, POMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [�7l 4 DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS ` FOUNDATION AGRICULTURE WELL _�,_�.- OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r pia. of Well Excavation Industrial ❑Open Bottom ❑Manteca Dia. of Well Casing Domestic/Private ❑Gravel Pack ❑Tracy KI ❑ Public ❑Other ❑Delta Type of Casing {[{ �❑ Irrigation Approx. Eastern Specifications ❑ Cathodic Protection i Depth Depth of Grout Seal ❑Geophysical �i Type of Grout r ❑Other Surface Seal Inst lled by Repair Work Done 1p Typeof Pump H.P. orf O R �1 � State Wk Done JLL� j ' Y Well Destruction ❑ Well1Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ❑ (No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION available within 200 feet.) Installation will serve: Residence — Commercial Other Number of living units:` Number of bedrooms Lot size Water table depth G Character of soil to a�Ii,depth of 3 feet: No. Compartments Type/Mfg Capacity SEPTIC TANK ElCapacity Method of Disposal � rn PKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Pro ert Line SEWAGE SYSTEM ❑ �. Distance to nearest: Well -------- DESTRUCTION iTotal length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation Size Number SEEPAGE PITS E] Depth Depth Foundation Property Line SUMPS ❑ !I`P Distance to nearest: Well a DISPOSAL PONDS ❑ II k III I hereby certify that Iihavetprepared this application and that the work will be done in accordance with San Joaquin county f ordinances, state laws,�and rules and regulations of the San Joaquin Local Health District, 111 Home owner or licensed agent's signature certifies the fmannernas to become subjectthat ntohworkmankmcompensathonwlawsfof California." permit is issued, I 'sha11 not employ any q following: certify that in the performance of the work for which Contractor's hiring or sub-contracting signature certifies the oowg: this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant ust �A� o all required inspections. Complete dr i g on`reverse side. 4. �n��c� Dater Title: ( Signed X R DEPARTMENT USE ONLY Area _ _�_ ❑ Stk 466-6781 Application Acc opted by ❑ Lodi 369-3621 Additional Comments: Date T Manteca 823-7104 Pit or Grout Inspection by _ Date ( �� ❑ Tracy 835-6385 Final Inspection by 1 n�vironmental Health Permit/Services 1601 E. Haze ton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return allikcopies4 E I RECEIVED BY DATE PERMIT N0. FEE BASE AMOUNT DUE. AMOUNT REMITTED INFO 31 3 a1s Q C� S 10/82 500 EH 13-24 REV, 10/82 14-26