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APPLICATION FOR PERMIT i t;`F� 'f $3 SAN JOAQUi"'LOCAL HEALTH DISTRICT J Uf `� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �� Telephone (209) 465-6781 'i G'I'N JOA `®UIN LOCAL PERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED DATE ISSUED 6 S H��"TH DISTRICT {Complete in Triplicate} v �I ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/,or install the work herein I 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 .-� 7 �7 �� r(� 1i��3 � pUbdivision Name/y . ! E Owner's Name `� , _ (1 (f�, C� _ Address i6 78 5 Lam' 127 (:, lL'F9 1,W] W'1 Phone 6) ` Contractor's Name "f �r� -�y� rj Soja License No. 1279b [ E PhoneV36-2,207, I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �� ` f PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Op DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FEB. 'i PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL I! PITS/SUMPS (r.1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U,I Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation 1; Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing i ❑ Public ❑Other ❑ Delta f Type of Casing Irrigation Approx. ❑ Eastern i! ❑ Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical ;k Type of Grout Other Surface Seal Installed by Repair Work Done tK Type of Pump H.P. State Work Done .'?�J � U Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') I! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is (n available within 200 feet.) yV Installation will serve: Residence _ Commercial _ Other i �] Number of living units: Number of bedrooms Lot size Character of soil to a.depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM -,i Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. A Length of lines Total length/size 1! r i l FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 71Depth Size Number 0 SUMPS L i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ °' sl 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. j 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 workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 app]ica� mus call +f r all qua red inspections. Complete dra ing on reverse side. '� 715. Signed X I; d � , -� Title: 09.._t.L/ Date: ARTM USE ONLY Application Accepte y . Area ❑ Stk 466-6781 4 Additional Commen ❑ Lodi 369-3621 Pit or Grout Inspectiony Date ❑ Manteca 823-7104 Final lnspection''by CJ1 � Da ❑ Tracy 835-6385 Applicant - Return all copies ta: Environmental Hf>h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 !i 7 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT NO. 4,S ` I9 16 3-5� EH 13-24 REV. 10/82 11 10/82 500 14-26 li II ..