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1 y APPLICATION FOR PERMIT AUG 2 31983 SAN JOAQU'I?l LOCAL HEALTH DISTRICT --.�a� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I SAN UIN LOCAL Telephone (209) 466-6781 DATE ISSUED' 14I-TH DISTRICT PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED (Complete i:O 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 i trict. Jab Address i4� 1j1,,�SubO7 n a r� • ` Owner's Name I„ Address Phone Contractor's Name IY1 icense No. Phone 4(f .3eln TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION J t a - _ -PUMP}INSTALLATION SYSTEM REPAIR ❑ OTHER 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 ❑ Open Bottom (] Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack [] Tracy Dia. of Well Casing 4 ❑ Public Other Delta J ❑ Type of Casing ` ❑ Irrigation Approx. ❑ Eastern Specifications I E]Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') - — Depth Filler Material (Below 50') 05 's TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION [J (No septic tank or seepage pit permitted if public sewer is available within 200,.feet.) Installation will serve: Residence _ Commercial Other Number of living ;units: Number of bedrooms Lot site , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK._ ❑r Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal { SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line k o DESTRUCTION 17 1 LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation' Property-Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Sari Joaquin Local Health District. 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, 1 shall not employ any person in such manner as to become subject td 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 issLAd, I shall employ persons subject to workman's compensation laws o California." The applicant m all for al uire i pectio s Compl to d wing on reverse sid . Date: --Signed X W R 0 PARTMENNL Area d 4 �` Stk 466-6781 `Application Accepted by E] Lodi 369-3621 Additional Comments: k 7104 ' JPit or Grout Inspection by Date p ❑ Manteca 835--63856385 /r Final Inspection by Date �2 —�7 L) Tracy $35 Applicant Return all copies to: Environmental Heald Permit/Services 160 L. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. - d4� a 10/82 500 ! EH -13-24 REV. 10/82 14-26