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D APPLICATION FOR PERMIT t� Qp SAN JOAQUIN LOCAL HEALTH DISTRICT JUN <r 11983 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 Sfi rq 10k' U IN LOCAL ( DATE ISSUED Lk t PERMIT EXPIRES 1 YEAR FROM DATE ISSUEJEALTIA DISTRICT (Complete in Triplicate) 1 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 ccmpliance 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 C-I Qr✓ kif Subdivision Name Owner's Name FPJ A)6_AW#ftres-% Sar,,,~e. Phone Contractor's Name -t D,, Q,l, S�"J License No. 0717,96Phoned , � A TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP ]NSTRLLRTIONSYSTEM REPAIRWIJ OTHER U i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I JIndustrial U Open Bottom Manteca Dia, of Well Excavation Domestic/Private F-] Gravel Pack Tracy Dia. of Well Casing (] Public F-1 Other Delta Li Irrigation Approx. Eastern Type of Casing Depth Specifications {Cathodic Protection p Depth of Grout Seal Geophysical LJ Other Type of Grout Surface Seal Installed by Repair Work Done K Type of Pump _S11. H.P. I State Work Done Well Destruction Lf Well Diameter Sealing Material (top 50') ` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is a (1J 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 m j SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED r7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line 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. M 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 workmanK 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 must all f all equired inspections. Complete drawing on reverse side. Signed X Title: _ (3;k�( Date: FORR MENT USE ONLY Application Accepted by - MLLI C1 an, Area r� �] Stk 466-6781 Additional Comments: F_] Lodi 369-3621 Pit or Grout Inspection y Date anteca 823=7104 Final Inspection by Date 'L7 Tracy 835-5385 Applicant - Return all copies to: Environmen 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 45 0 EH' 13-24 REV. 10/82 x raj /Jr� 10/82 500 }E 14-26