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APPLICATION FOR PERMIT- �. DEC ��{�� SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. v 1601 E. HAZEL-TON AVE., STOCKTON, CA, ISSUED �� ' I Telephone (209) 466-6781 DATE SAN JOAQUIN LOCAL PERMIT EXPIRES 1'YEAR FROM DATE ISSUED HEALTH DISTRICT (Complete in Triplicate) 11 rein Application is hereby made oto'the San de inocompliLocal wHthlSanDJoaquin Countyp0 dinanccecNo. 549tfor dsewage sOrlNO- IB62l the rfor ewell/pump described. This appltica and the Rules and Re ulallons Of s�e�.San Joaqu'n Local.Health ubdivision Name mor ad2l Job Address t `� l�� same Phone It �, , ,. Address Phone 931.-3210 Owner's Name M�ense No. I Vv Contractor's Named ' \ NT" ❑ DESTRUCTION NEWWELL WELL REPLACEME ❑ j TYPE OF WELL/PUMP WORK: Q OTHER ❑ -� U` Y PUMP INSTALLATION SYSTEM REPAIR ❑ PROP LINE ZT JSEWER LINES d DISPOSAL FLO. DISTANCE TO NEAREST: SEPTIC TANK ;z _ OTHER WELL _ PITS/SUMPS ZA!&_9,00-- FOUNDATION �� '�� AGRICULTURE WELL �� CONSTRUCTION SPECIFICATIONS _INTENDED USE TYPE OF WELL PROBLEM AREA _ Dia of,Well.Excavation-�- en Bottom, []Manteca T ❑ Industrial Xp Dia. of Well Casing mestic/Private ❑Gravel Pack ❑Tracy ❑Other ❑Delta Type of Casing ❑ Public F-11.rrigation Approx. E]Eastern Specifications , -Depth Depth of Grout Seal * ❑Cathodic Protection �❑G � Type of Grout eophysical y Surface Seal Installed by ❑Other i' r State Work Done r Type of Pump gLt}J." Sea Repair Work Done Sealing Material (top 50') Well Destruction ❑ Well Diameter Filler Material (Below 50') Depth available within 200 feet.) TYPEOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ {No septic tank or seepage pit permitted if public sewer i Commercials rt Other T Installation will serve. Residence _ Lot size Number of living units: Number of bedrooms _ Water table depth Character of soil to a depth of 3 feet: Capacity _T_� No. Compartments SEPTIC TANK F-1 Type/Mfg Method of Disposal Capacity JKG. TREATMENT PLT. �] Type/MI Foundation Property Line SEWAGE SYSTEM Q Distahie to nearest: Well DESTRUCTION r - � Total length size LEACHING LINE �J No: &`Length of lines Property Line 4 ❑ Distance to nearest; Well Foundation P y -� FILTER BED k Size SUMPS Number SEEPAGE PITS [] Deptht 1 SUMPS t ❑ Distance to nearest:' Well Foundation Property Line DISPOSAL PONDS ❑ ordinances, statethat I have and ralepared this regulations nand the that the nwork w 1ealthd0istrone nctccordance with San Joaquin county Home owner or licensed agent's signature certifies the following: "I certify that in the performance ns the work for which this permit is issued, 1 shall not 'einploy any person-in-such manner as to become subject to workman h compensation laws of California."i Contractor's hiring or sub-c ntractingpersonsusubjectcertifies workman�slcompensationcertify laws ofCalifornia."that in the of the work for which � this permit is issued, ,. The applicant t1-X I o 11'required inspections. Complete drawing on reverse side. Date: 12-9-83 Title: Signed X . c pEPARTMENT USE ONLY Area _^ Stk 466-6781 i Application Accepte by ' Lodi 369-3621 Additional Coments: Date ❑' Manteca 823-7104 Pit or Grout Inspection-by eats-�a�►�@3 �"`` ❑-Tracy 835-6385 4 Final Inspection by ��_- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E,'Razelton Ave., P.O. Box 2009, Stk., CA 95201 RECEIVED BY DATE PERMIT NO. t [FEE BASE ->' AMOUNT DUE AMOUNT REMITTrO f�J `- a3 U✓�.�3i0� { 10182 500 EH 13-24 KV. 10182 - 14-26