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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. x,-3_23 Telephone (209) 466-6781 ` DATE ISSUED f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 . {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 it 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 Sd /7-7 ! Subdivision Name Address Phone Owner's Name P e(- � Contractor's Name 0 on CI< a frvmicense No. C Q Phone �''�i/7 /93 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION ❑ _. . -P_UMP,.INST4L-L�ATI-0N— --��Sll•SdEIk�2EPATR� "`�e +.�w.+�. THER �'C � U � - rwm " V1 � � � "a' �-DISP SAL FLD. PROPI LINE r DISTANCE 70 NEAREST: SEPTIC TANK - ,SEWER LINES a,. bo r FOUNDATION tAGRICULTURE`,,WELL OTHER WELL PI -,I- FOUNDATION to LJ i F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FD Industrial U!Open Bottom �] Manteca Dia. of Well Excavation I U Domestic/Private []IGravel Pack Tracy Dia. of Well Casing r k ; Public Other Delta Type of Casing Ljirrigation Approx. LJ Eastern Specifications p Cathodic Protection p Depth - Depth of Grout Seal Geophysical l` > Type of Grout 1 t # Other I Oer I Surface Seal Installed by ( Repair Work Done ❑ Type of Pump H.P. State Work Done x. g Well Destruction U Well Diameter Sealing Material (top 50') Depth f Filler Material (Below 50') S � f TYPE OF SEPTIC WORK: NEW INSTALLATI�ONN, --<RCPAIR/ADDITION Lj (No septic tank or seepage pit permitted-if public sewer is available mi"thin 200 feet.) Installation will serve: Residence Commercial Other E Number of living units: `.Number of bedrooms._ k Lotsize Z 9 'Y, Character of soi 1 l to a depth.of '3 feet: f��Q i ATI r Water table depth .SEPTIC TANK d]1 Type/Mfg /� TC S / `Capacity .2b Q No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of-`Disposal t SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION 1 1 I LEACHING LINE No.p& Length of lines y- Total length/size ( FILTER BED Distance to nearest: Wel Foundation Property Line lh " SEEPAGE PITS ❑ Dep'jth Size Number SUMPS L� Di to nearest: Well Foundat oh's "`'� Property" Line ' DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done inn-accordance with San;haquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y ¥ Home owner or licensed agent's signature certifies the following: "I certify that in the,performance of the�work'for which this C permit is-issued, I shall not employ any person in such manner as to become sdbject to,`'w6rkman$-compensation�l•aws of aiifornia. Contractor's hiring or_sub-contracting signature certifies the following: "I certify' thaAin thei-07 °fbimance.of te work for which this permit is is ued, I shall. employ persons subject to workman�s compensation laws of California." The applicant ally allrequired inspections. Complete drawing on reverse side, Signed X Title: ��,A n 1 _ Datex: FO T'NfE DNLYprea (] Stk4 6-6781 , Application Accepted by s s Additional'Comments `` " L di-. X369-3621 Pit or Grout Inspection by ate -` Final Inspection by Date Tracy ' 835-6385: Applicant - Return al co s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, St k.,'CA 95201 -FEE BASE"BASE"--.._.RMOUNT DUES., .-_ AMOUNT REMITTED'" RECEIVED BY DATE PERMIT N0. INFO 23 EH 13-24 REV. 10/82 / yy_ 10/$2 500 aLl1 eli b"c-- 14-26 t�