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Q r; :.4 APPLICATION FOR PERMIT SAN JOAQbiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, y Telephone (209) 466-6781 pp DATE ISSUED 9 O 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 /F7fc Al ON 125 Z.( A'A lib Subdivision Name Owner's Dame A�JIAEL_VAI dOu,1T-S Address 1%461 A= Phone Contractor's Name F1.�YA 46, U100b License No. 4-24727-4, Phone y4/—3`-7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION F-1 SYSTEM REPAIR ,= U OTHER LJ 1 w 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 J Industrial U Open Bottom ❑ Manteca { Dia. of Well Lxcavation Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing 17 Public { Other Delta I I I Type of+ Casing f-1 irrigation Approx. Eastern [ Cathodic Protection Depth Specific If Depth of;rout Seal 17 Geophysical Type of Grout U Other Surface SealiInstalled by Repair Work Done ❑ Type of Pump H.P. State Werk Done Well Destruction U Well Diameter Sealing Material (top 50-)'Ai b� Depth Filler Material (Below�SO'j;k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'' (No, es ptic�tank orseepage-pitpermitted if public sewer is ;ailable within 200 feet.) Installation will serve: Residence Y Commercial _rt Other Number of living units: ___t_ Number of bedrooms _ Lot,4size F fy_ ve Character of soil to a epth of 3 feet: 40 -A Y _ +�+ ' I A D G later table depth SEPTIC TANK Type/Mfg �L Capacity ^...__ No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity .Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation N.30 Property Line 20 DESTRUCTION ❑ I pl-ft" Prd J LEACHING LINE No. & Length of lines /�' �Y} Total length/size X -Y FILTER BED Distance to nearest: Well Foundation— d fk Property Line fl _ SEEPAGE PITS Depth -)'r i Size 11 Number:' � I SUMPS Distance to nearest: Well ��•�* Foundation 1,0b Property Line DISPOSAL PONDS CI l� 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 yollowing:. "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in,such:�nanner,as.to,become,subject to workmanh 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 call for all requirAd inspections. Complete drawing on reverse side. Signed xU Title: Date: 4-9?P3 FOR DEPART ENT U NLY Application Accepted by . Area 0 K—Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by —71 Date �d. Manteca 823-7104 Final Inspection by n Date7 AJ L7 Tracy 835-6385 Appiicant - Return all copies to': Environmental Health Permit/Services 1601 E�Hazelton Are., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. INFO Ste- °t. 'S -q7S EH 13-24 REV. 10/82 10/82 500 14-26