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em 7 APPLICATION FOR PERI;T SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. jOf Telephone (209) 456-6781 DATE ISSUED ;r 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 4 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump"e and the Rules and RRerg7ulationsof,the San Joaquin Local Health District. y Job Address 887/ MoulaT rum V»l )?OAA�,bdivision Name Owner's Name ,� {�6HIr/s' Address Phone 6 2 Coy Phone Contractor's Name I/1? CAftlle License No. y /$ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION �. PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPCSAL FLO. PROP. LINE FOUNDATION + AGRICULTURE WELL OTHER'WELL PITS/SUMPS I INTENDED USE TYKE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom j] Manteca Dia. of Well Excavation ` J U Domestic/Private GDia. of Well Casing Pack �Tracy g j Public [� Otlh1er Delta Type of Casing V Irrigation 41 Approx. EJ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Purap H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth ` Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LVI REPAIR/ADDITION ❑ (No septic4ank or seepage pit permitted if public sewer is available within 200 feet.) IInstallation will serve: Residence X Commercial :Other k_ Number of living units: 1 Number of bedrooms ✓may y Lot.size �� Zag r Character of soil to a depth of 3 fee : O� .. Water table depth SEPTIC TANK Type%Mfg �eCd15 Capacity9 00 No. Compartments Capacity `: Method of Disposal PKG. TREATMENT PLT. ❑ Type/.Mfg i SEWAGE SYSTEM Distance to nearest: Well `00 Foundation Off" Property Line DESTRUCTION ❑ 1 f f �_ �Q — O Total 1 ength/size LEACHING LINE U Na. &Length of lines � FILTER BED Distance to nearest: Well 100H Foundation 90' v Property Line 5� SEEPAGE PITS Depth Size $ A' 12 t Number S'U I SUMPS Distance to nearest: Well /001 Foundation �� Property Line DISPOSAL PONDS ❑ 11 r' n and that the.work will be done in accordance with San Joaquin county I hereby certify that I have prepared this application ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ,, this he work for which;5'. Home owner or licensed agent's:signature certifies the following: "I certify that in the performance of t . permit is issued, I shall not employ any person in such manner as to become subject to woornia." rkmant compensation laws of Calif Contractor's hiring or sub-contracting signature Certifies the following: 'I certify that in the performance of the work for which 1 this permit is issued, I shall employ pe sons subject to workman's compensation laws of California." y The applican call fqp aleequir�inspections. Complete drawing on reverse side. Signed X7 K C_' ��CCC Title: Date: F RTMENT USE ONLY ❑ I Application Accepted by1 Area L Stk 466-b781 Lodi 369-3621 Additional Comments: ` Date Manteca B23-7104 Pit or Grout Inspection by 21- Oate ED Tracy 835-6385 Final Inspection by Applicant - Return all copies to: . Envir ental Health Permit ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0.L !f 10/82 500 EH 13-24 REV. 10/82 ' 14-26