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APPLICATION FOR :PERMIT ` �. I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 'E. HAZ£LTON AVE., STOCKTON,'CA PERMIT;IVO, i Telephone (209) 4664781 ,DATE 'ISSUED, 1 I� PERMIT EXPIRES I YEAR ,FROM-DATE ISSUED !! (Complete in Triplicate)- ,,Application is hereby made to the-San .Joaquin Local Health District fora .permit to construct:and/or install the work-herein described. This application fs made in compliance with San Joaquin .County Ord_inance.No, '549 for sewage or No..'1862 for well/pump and the Rules and Regulations of the San Joaquin Local :Health District, Job Address Subdivision. Name ..Owner's Name i AN Address ,� Ifd� S-N�.�:r>Tr�.�l_�_Phone Contra_ctor's NameLicense No. TYPE OF WELIAUMP WORK; NEW WELL WELL REPLACEMENT DESTRUCTION ' II U'- PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER [ t DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES DISPOSAL FLD PROP. LINE T r� FOUNDATION AGRICULTURE WELL OTHER WELL PI ysumps V }� INTENDED USE I'. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; l Industrial 0 open_Bottom Manteca. Dia. of Well Excavation : Domestic/Private "I]GravelPack ._ Q Tracy Dia, of Well Casing _ Public [j Other Delta . Type of Casing i Irrigation i� Approx. []Eastern Cathodic Protection Depth Specifications p Geophysical d Depth'iof.Grout%Seal .a 1. Type of Grout _ ��Other ii _ Surface Seal Installed E Repair Work Donee Type of Pump H.P. State Work done Well Destruction 17 Well Diameter__ _ Sealing Material ,(top 501) Depth�� Filler Material (Below 509 ^ 'TYPE OF SEPTIC WORK: NEW INSTALLATION 4 REPAIR/ADDITION .0 (No septic tank or seepage pit permitted if+public.sewer is available within 20D .feet`). !Installation will serve:I) Residence_Z Commercial Other x i ,Number of living units:-11__�, ,Number,of bedrooms _ Lot size k ' kCharac.ter of soil to a depth of•3'feet:� t�� Water table depth. SEPTIC TANK c� Type/Mfg l��- .r - -^ 'Capacity, No. Compartments,'`�L - KG. TREATMENT PLT. © type/Mfg �--� '""' :Capacit'y Method of Disposal ' Distance to nearest: Well -*Fourdition' Propdrty Line, Septic Tank r In , LIENo. & Length of lines .. Total length/size :: FILTER BED i �' Distance to nearest Well / Foundation 'e,� Property tine, U F SEEPAGE PITS DepthSize SUMPS- Distance to nearest: Well ;Foundation. Pro er, Line I_1 P,.tY S ^v ' �DISP05AL' PONOS � ,� ... � ��•� � ,-_ y - . _ '. I "hereby certify that I have prepared this application and that th ork will 6e done,in ac4ord-nce with-.San Joaquin county- t ordihances, state laws, and rules and regulations of the San Joaqdin,`Local Health 'District Hgme owner or licensed agent's signature certifies the following: "'I certify that in-'the.performartce:ofjthe work�for which this. f i pe-iiit is issued, I shall not employ any person in such manner as to"become subject ta.workman's c�npensatian-lawsfof-California:" Cohtractbr's hiring or sub-contracting signature-certifies.:the following! "'I certify that iri the.performance:of the,work for which this .permit is issued, I shall employ persons subject to'workmah's :compensation laws of'Cal ifornia." � „- { 4Mhe.applicant must call r l required inspections� Complete drawing on reverse side. tS1.gned X__ /� .__� ai Titre. - .c -,-' _ Date; cel� F,OR DEPARTMENT USE'.-ONLY Application Accepted byArea y;3 ❑ Stk 4666781 Additional' Comments: [J Lodi' , 969462.1 pit or Grout Inspaction by Datentica 829.7104 Final Inspaotion by Deta - ' []. Tracy 8315 686 Ap01pant Return;all copies Invirartmentat Health Parmit/Services 1661 E. Hazelton Ave„ P;O, 60x4009,.Stk., CA 116201 i FEE CASE AMOUNT DUE AMOUNT REMITTED 'RECEIVED BY DATE "1ERMIt NO. } INFO ..EH-1344_..'REY, '10/82' _ ... - ,..... _ . .._ - 10/82 Boo1446 r . 1 . s