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APPL CA ON R PERMIT ,r r' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1 y '�g Z- Telephone.(209) 466.6781 GATE 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 WU A 1"J.V0 S1+ Subdivision Name Owner's Name _fie�jev Address Phone Contractor's Name� ��Q�l/ 77rLfCL/�tiL�_ License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (❑ SYSTEM REPAIR OTHER Lj DISTANCE TO NEAREST: SEPTIC TANK -- Q� SEWER LINES DISPOSAL FLU. PROP. LINE --Zg5;? - FOUNDATION 6,5 1 AGRICULTURE WELL r{' OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a/� I❑-Industrial--- T0pen Bottom ❑ Manteca -- Di a.,of-Wel l--Excavati,on- iii Domestic/Private ❑ Gravel Pack ❑ Tracy _ Dia: of Well Casing ❑ Public ❑ Other• ❑ Delta Type of Casing F, irrigation Approx. Eastern Specifications /0 6//- Protection Depth ❑ Cathodic rotec AIL- Geophysical - - Depth of Grout Seal �`� "�' _ f ❑Geophysical r + Type of Grout F 40GL 7 ❑Other ` Surface Seal Installed by C7[B ayo/ PM CC/,.Vg A Repair Work Done ❑ Type of Pump H.P. State Work Done J 7 Well Destruction Well Diameter Sealing Material (tap 50') Depth 3l.- Filler Material (Below 50') S V V, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence- 'Commercial Other Number of living units: Number of bedrooms Lot size Character of sail 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 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ^ SEEPAGE PITS Depth Size Number SUMPS 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 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." AF The applicantmust call f r`all re ' ed inspections. Complete drawing on reverse side. a� e Date: Signed X'+ Title: ,� � 6c°.E—�� F R TM USE ONLY - Area Stk 466-6781 Application Accepted by �7.. K = Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 3—z� -�� L Tracy 835-5385 Applicant - Return all copies to:' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f 10/82 500 EH 13-24 REV. 10/82 14-26