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APPLICATION FOR PERMIT SAN JOAQUN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ' DATE ISSUED r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 Rulesa d Re ulationsof the?Sar Joaquin Local Health District. Job Address 946 3 Not-tTtiLAND RJr Subdivision Name Owner's Name RAU LARIFY pRe Address me- Phone Contractor's Name Att(�ILlc License No. Z391 13 Phone 239 2126 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP�:INSTALLATION' [Z L ',SYSTEM v REPAIR ❑ OTHER LJ- w. a-• .. .-•,..,, .... ....�-••.�..v.- _. 1 TANCF_TO-,NEAREST:.SEPTIC_TANK € _SEWE_R LINES_ DISPOSAL FCD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE rTYPE OF,WEL`L PROBLEM AREA CONSTRUCTION SPECIFICATIONS ~a ;❑ Industrial I ❑ Open Bottom ❑ Manteca pia. of'.W11 Excavation i ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of.Well Casing f Public Other Delta I 1I ❑ ❑ ❑ 4 Type of,-Casing ❑j Irrigation Approx:- Eastern Specifications F-1 Cathodic Protection Depth Depth o.f' Grout Seal +1++u.; a s ❑Geophysical Type of Grout_ # ❑Other Surface Seal Installed by Repair Work Done Type of;Pump w H.P:.� State Work Donel Well Destruction ❑ Well Diameter. �- ° Sealing Material (top 50'} # Depth I Filler Material (Below 501 ! ;h IN TYPE OF SEPTIC WORK: NEW INSTALLATION FO REPAIR/ADDITION T+5(Notseptic tank or seepage pitfpermitted if public sewer is .. yai+able-within 200}feet.) Installati_o will serve: R651dence Commercial OOtther Number of living units: ►'"rNumber of bedrooms .e Lot.. ze . 00` X y��' Gln, k -�-. - • !� Charactef soil to a depth of 3; _feet: IV Y. Water table depth ^`u r € 70 SEPTIC TANK Type � s ; ts 2 MfCaPacity X20 '�'-_No.�Compr-tmen PKG. TREATMENT PLT. ❑ ITy O/Mfg .-` *^^* Capacity ' + Method of I'pU-sal t� SEWAGE SYSTEM f Distance to nearest: Well Foundation~, -Property Ltne DESTRUCTION ❑ f ` , .� f %.> LEACHING LINE No. & Length of lines �! I p�r -Total length/size $ FILTER BED ❑ Distance',to nearest: Well Foundation . . Property Line 1 i, SEEPAGE PITS Depth �0.` ` Sizo X Number �. - SUMP, � ❑� Distance to nearest: Well Foundation Property Lin DISPOSAL PONDS ❑ ' ( f I hereby cert ify.that I havefprepared;tfiis-application and that the work will be done in accordCe wi5an Joaquin county s ordinances, state laws, and rules' and regulations of the San Joaquin Local Health District. 1T 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, I shall employ persons sub j to workman's compensation laws of Cal'ifornia." i The applica call for"' 1_requ ed inspections. ,Complete drawing on reverse side. I Signed X � � � - _ / '`., _"Title' 'D�dJ'N�1��- Date: i F D �RTMEN SE ONLY 3p �� # t Area '*� � [] 4tk 4fi6-6781I I Application Accepted by { Additional Comments: r— Lodi 3b9-3621 , E Pit or Grout Inspection by DateManteca�823-7104 a f r-^ ` •� Date ¢S J ❑ Tracy;835-6385 1 Final Inspection by Applicant - Return all copies to: Environmental H alth Permit/Services 16 1 E. azelton Ave., 'P.O. Box 2009 Stk.' CA 95201 App p -;fnta i t FEE BASE AMOUNT DUE AMOUNT"REMI'TTED ..r RECEIVED BY w ' DATE PERMIT N0. i INFO 10/82 500 EH 13-24 REV. 10/82 14-26 I