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f APPLICATION FOR PERMIT # SAN JOAQ6i'N LOCAL HEALTH DISTRICT ! - 1601 E. HAZELTDN AVE., STOCKTON,' CA PERMIT NO. Telephone (209) 466-6781 ; DATE ISSUED PERMIT EXPIRES 1.Y EAR 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 2C r, l 94V_10 Subdivision Name ~ `��t��. Owner's Name p � ` .Address n Phone Contractor's Name �g , ,{z License No, �.�`y�— y _- _ Phone y�j(j—��7 k i TYPE OF WELL/PUMP WORK: NEW.WELL ❑ rWELL REPLACEMENT ❑ DESTRUCTION ❑ p4� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ) FOUNDATION AGRICULTURE WELL_ OTHER WELL PITS/SUMPS - ,- ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C} 1O[} ! ❑ Industrial ❑ Open' Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy_..µ, .,_ Dia. of Well Casing _J t ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern t Specifications r ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout Other g3;Surface Seal Installed by Repair Work Done.D Type of Pump H.P. State Work.Done . e k Well Destruction ❑' `Well-Diameter Sealing Materia71'(tog~50'.).._ I Depth Filler Material .(Below 50'.) Q TYPE OF r$�EPTIC WORKNEW,INSTALLATIDN REPAIR/ADDITION ❑a(.No septic;tank or seepage •pit permitted if public sewer is d } ava'ilatile'within 200 feet:) ` Installation will serve: Residence Commercials_ (Other X y F f i Number of living;units: A.Number of bedrorrg.XA . :Lot;size OD n "�"leg' Character of-soil to a deptYi`61`3 feet: r Nate','tableZdepth 501 T'10TANK � Type/Mfg Capa-city' f'ZB� In Gompar-Cmen.tr Z PKG. TREATMENT PLT sQ Type/Mfg _ ""'* •.Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well �SZ7 Foundation /O Property Line DESTRUGTIoN��- t7 k I G r x LEAGH[NG LINE No. & Length of line Total length/size / p ae f I { FILTER BED ❑ Distance to nearest: ' Well /,gB Foundation -- Property Line SEEPAGE pITSfi igj ��Depth Z� Size . Number SUMPS ❑I Distance to nearest: Well /p,0 Foundation Property Line DISPOSAL PDNQS' ❑ tr I I hereby-certily-thatr�--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 Loeal 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 become subject to workman§ 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 must �alfor all ui®rederons. Complete drawingon.re+ rse sidSigned X � Title: ./'J �i.® Date: ? RTMENT E ONLY Application Accepted by Area y� ❑ Stk 466-6781 F Additional Comments::"-, -- r 4t =c-" = `" ` ❑ Lodi 369-3621 Pit or Grout Inspection by Date + 6 Manteca 823-7104 --Date .Applicant - Return all cov pies}to: . Environmentarl,Healthw.Permit/services160}l: Hzelton Ave., P.O. Bax 2009, Stk„ CA 95201 [INFO E BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY p DATE PERMITT NO. Q D ' EH 13-24 REV. 10/82 10/82 500 14-26