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APPLICATION FOR PERMIT IT - AUG r� pA AN JOAQUi ; LOCAL HEALTH uiS7RICT I~',U G 2 2 1138 t 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NC. Telephone (209) 466-6781 SIGN JOAQUIN L_OCALPERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED HEALTH DISTRICT (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address W031 6, M;I a Rd, Subdivision Name /Alpy A /� KPhone u*cr– Owner's Name Jae 4 knr M Address .� u«5`� Contractor's Name pUrylgpC*Dd11eMDd11JngCffPense No. I I I IA-3Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ;_7 OTHER U DISTANCE TO NEAREST: SEPTIC TANK rQQ� SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4" J Industrial P(j Open Bottom Manteca Dia, of Well Excavation Domestic/Private F-1Gravel Pack E] Tracy Dia, of Well Casing L/d e lI Public �J Other Delta Type of Casing �J�� Lr/ ,GfT Lj Irrigation 21Q' Approx. Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout SQA � �Gimp#tr LJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump —S' b -- H.P. State Work Ione ` Well Destruction U Well Diameter Sealing Material (top 50') CAFJh a�4yb, T�" ;* Depth 2_'1 Q i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION �_J REPAIR/ADDITION U (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 soil to a depth of 3 feet: Water table depth SEPTIC TANK EI 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 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS l-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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. 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, I1 employ persons subject to workman's compensation laws of California." The applic t must C 1 fo all required inspections. Complete drawing or reverse side. p Signed X Title: Date: p 26!—,QEF FOR DEPA ENT E ON.LY Application cepted bf`/ — 4f ea Stk 465-6781 Additional Comments: ;� Lodi 369-3621 Pit or Grout Inspection by Date p� �Q U Manteca 823-7104 Final Inspection by Date 7 ❑ Tracy 835-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �. $1�—lo$I EH 13-24 REV. 10/82 10/82 500 14-26