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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 yy p DATE ISSUED PERMIT EXPIRES 1 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 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 5W6/ -Z.0WeX_ .SACk4l Subdivision Name 0C AJ Name Owner's Namy - 4a &&WAs �(3 t-2� l��\�' -,�j f'�L/fcr- Phone Contractor's Name = License No. .30 a_i Phone r_TY.PE OF,WELL/PUMP WORK: NEN WELL WELL REPLACEMENT DESTRUCTION Lj 1 t4 PUMP INSTALLATION (] SYSTEM REPAIR OTHER r�1 { DISTANCE TO NEAREST.: SEPTIC TANKy "[ SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION *1 AGRICULTURE WELL OTHER WELL PITS/SUMPS ,fi INTENDED USES TYPE OFIWELC- f PROBLEM AREA CONSTRUCTION SPECIFICATIONS o� Industrial ",u Open Bottom Q Manteca Dia. of Well Excavation • F Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing Public F-1 Other Delta x Type of Casing V Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical U Type of Grout Other Surface Seal Installed by Repair Work Done Type of Pump H.P. w State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth F'iller' Material (Below 50') TYPE OF SEPTIC WORK NEW INSTALLATION REPAIR/ADDITION .D (No septic tank or seepage pit permitted if public sewer is v ' available within 200 feet.) Installation willrserve: Residence _ Commercial C---Other Number of living units: Number.ponf��lbedrooms Lot size Character of soileto a depth. of 3-,feet: AdoeAA " :Water table depth SEPTIC TANK Type/Mfg ^ 00v CQ Capacity ( No, Compartments PKG. TREATMENT PLT.; Type/Mfg",, " Capacity Method of Disposal SEWAGE SYSTEMDistance" nearest: Well ( f Foundation L(7 _ .-Property Line_ _ y DESTRUCTION LEACHING LINE (.tom" No. & Length of lines t - f3 f Total length/size �fj FILTER BED Distance to nearest: Well _` Foundation 3 R Property Line 7 SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation { r Property Line TS- DISPOSAL PONDS ED k 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. ;11 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 workmanS 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 hall e lay persons subject to workman's compensation laws of California." The appl " usal for al required inspections. Complete.drawinngon reverse side, Signed Title: 49 60 A" Date: ///004F • Application Accepted by R DEPARTM SE dN Area 5tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 Final Inspection by Date {" -�f L{ Tracy 835-6385 Applicant - Return all copies to: . Env amental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ • FEE BASE AMOUNT DUE AMOUNT-REMITTED RECEIVED BY F11 . DATE {� PERMIT NO. INFO ; U 3.-P -4 EH 13-24 REV. 10/82 10/82 500 14-26