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APPCTCAT1ON FOR PERMIT , SAN JOAQUIN LOCA3_ HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 8?r $p F Telephone (209)-466-6781- DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED v. 1 a tom=.;;; Q- '(Complete in Triplicate) c a ; 04 Applteation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc n bed. This application is made in compliance with San Joaquin County Ordinance No. 549 for'sewage or No. 1862 for well/pump S} and the Rules d Requiations of the San Joaquin Local Health District. Job Address1 �� SUbdlVislOn Name Owner's Name L K rL0 N Address Phone. 3L�-• Z3�0 Contractor's Name Z.`y Q License No. Phone I r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION E PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 71 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPDSAL PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL yf PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS (� ? 'Industrial U Open� A Bottom Manteca Dia, of Well Excavation o� Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public fJ Other6 /-+S Delta w le-S3 1 Irrigation Type of Casing J ,� w'1 a �. �I 9 Depth Eastern Specifications Cathodic Protection Depth P 17 Geophysical Depth of Grout Seal •.-- U other Type of Grout Surface Seal Installed by ep N e Z Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction U Well Diameter; Sealing Material (top 501) V Depth Filler Material (Below 501) i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION 0 (No septic tank or seepage pit permitted if public sewer is 1 . S,v Installation will serve: Residence Commercial � Other available within 200 feet.) Number of living.units: Number of bedrooms Lot Size Character of soil to a depth of 3 feet: Water table depth rt°� SEPTIC TANK Cj Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distancelto nearest: Well Foundation Property Line ' DESTRUCTION L� f LEACHING LINE Lf No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth I Size Number SUMPS �� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI � { Yli� ' Igil�I�nYn� III- Itll��lll0� `�' 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 became subject to workmanis 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 applicant call for a d in5pections. Complete drawing on everse side. Signed X r Title: CdI✓s� ,�/'� Date: NT USE ONLY i Application Accepted by C RDEPARTMEArea Stk 466-6781 0 Additional Comments: U Lodi 369-3621 Pit or Grout Inspection by s Date 7 Manteca 823-7104 - Final Inspection by } Date /0-2c,9'5 ED Tracy 835-6385 ) Applicant - Return all copies to: to r nmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 { FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 PCAA W`N\ C( -f--CK*1 006 10/82 500 14-26