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APPLICATION FOR PER"; SAN JOAQUJN LOCAL hEALT4, DISTRICT PERMIT N0. 77 1601 E. HA7ELTON AVE., STOCKTON, CA ? Telephone (209) 466-6781 CAT ISSUED c� J 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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well described. This application is a San ./pump al Health District. and.the Rules and Regulations of th{AI San joaquif Loc t �ti i_. �fi��1�J� Subdivision Name hone Job:Address la��"-Y Address `� J Owner's Name D� CYC — .I vim` Phone License No. SRV Contractor's Name WELL ❑ DESTRUCTION ❑ ,�` NEWIWELL OTHER ❑ y TYPE OF WELL/PUMP WORK: w SYSTEM REPAIR � I �.} PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE 1 DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES� � OTHER WELL ��.'_ PITS/SUMPS , AGRICULTURE WELL _ FOUNDATION p> '= `Y CONSTRUCTION SPECIFICATIONS SNT£N�ED USE �1 TY?E OF WELL PROBLEM 4 .' �t ❑ �]Manteca + S Dia. of Well Excavation F-lindustrial OpeniBottom Dia. of Well Casing ❑ Domestic/Private Gravel Pack Tr-acy.,,,l__, Public ❑Other Delta Type of Casing Approx. ❑Eastern Specifications LJ [rriga.tion ,�. Depth ❑Cathodic Protection Depth of Grout Seal LD Geophysical Type of Grout Surface Seal Installed by R ❑Other. State Work Done Repair Work Done E] Type of Pump. H.P. ti Sealing Material (top 50') ; Well Destruction ❑ Well Diameter Filler Material (below 50') .Depth S REPAIR/ADDITION (No septic tank or seepage pit availableed if withinu200cfeet.),'s TYPE OFRSEPTIC WORK: NEW INSTALLATION ❑ i ^l 1. V G j/ Commercial Other Instal,lation -will-serve: Residence y Lot size!' Number of living units: 1 Number of be Water table depth C Character of soil to a deo h of 3 feet: Capacity �� No. Compartments , F SEPTIC TANK � Type/Mfg Capacity L� Method of Disposal Y q PKG. TREATMENT PLT. L-J Type/Mfg Foundation Property Line _ ��— SEWAGE SYSTEM Distance to nearest: Well #=2- /1V-7- DESTRUCTION t Length of lines '�'T e Total length/size', _om LEACHING LINE No. &j Length ---^�+Pr�pgrty,Line n _ � � FILTER BED Distance to nearest: Well size Number r SEEPAGE PITS UJ Depth� � pru ert .Line -�Foundationp- y - ��""" SUMPS �� Distance to nearest: Well k .-. DISPOSAL PONDS; ❑ #� 'i ared this application and that the work will be done in accordance with San Joaquin county � I hereby certify that 1 have prep , ordinances, state laws, and rules and regulations of the San Joaquin Local Hethat in the per �alth District. compensation laws of California." �+ Home owner or licensed agent's signature certifison es fie' fouch annernas to becomeyScbject to worat knatheaperformance offkthe r orkcfor hwhich.. permit is issued, I shall not emp y, Y Contractor's hiring or sub-contracting persons subjectif.o the following: "I Y this permit is issued, I shall employ persons subject tc moletendrawincompensation verselaws side California." J� 11 required inspections, P g Date: ' The applicant must cal �I % `� Title: Signed Xk .. �• �-- 466-6781 40, r FOR DEPARTMENT USE ONLY Area �� ❑ Stk ` ; Application Accepted by� [3 ca 369-3621 s Additional Comments: Date -Marto 823-7104 Trag 835-6385 Pit or Grout Ior by io 4 by Date Final In by 0. , Applicant - Return all copies?to: Environmental Health mit/Services 1601 E. Hazelton Ave., P.O. Bax 2D09, 5tk., CA 9 ' T REMITTED RECEIVED DATE PERMIT NO. AMOUNT BY f E AMOUNT DUE FEE BASE, i IO/B2 5 £H 13-24 REV. 10/82 V 14-26