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APPLICATION FOR PERMIT l� fff SAN JOAQUiN LOCAL HEALTH DISTRICT I' 1601 E. HAZELTDN AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 far sewage or No. 1862 for well/ um and the Rules and Regulations of the San Joaquin Local Health D"tstrictP p . Job Address Subdivision Name �jli .�, l,a�� 34 Owner's Name IVAddress bViA)41 / Phone License Na. l Contractor's Name " �G�r A& Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , `"""PUMP-l-NS7AL•L-AT1-ON---❑....,t,,..SY-STEN-RE-PA-I"R---,-_❑..-.....,_...,,.._-OTHER—U-- .—_„ P. DISTANCE TO NEAREST: SEPTIC TANK — W 5EWER LINES DISPOVL FLO. PROP. LINE j r FOUNDATIONAGRICULTURE WELL OTHER WbL-I,_ PITS/SUMPS Q INTENDED USE i _. TYPE OF,WELL .a PROBLEM AREA CONSTRUCTION SPECIFICATIONS M I❑ Industrial � 6'en'Bottom � �`"4U R � ❑ Mahteca� Dia, of Well Excavation � Domestic/Private ❑gavel Pack-r, Tracy ` ❑,. �y�� Dia. of Well Casing ❑ Public ❑ Other ❑ Delta V irrigation Type of Casing i g 1 Approx. ❑ Eastern Specifications F-1CathodicProtection Depth p ❑Geophysical Depth of Grout Seal F-1 Other Type of Grout Surface Seal Installed byO e Repair Work Done ❑ Type of Pump H.P. State Work Done .�} Well Destruction ❑ iWell Diameter Sealing Material (top 501) I Depth Filler Material (Below.50') _ TYPE OF SEPTIC WORK:k NEW INSTALLATION% REPAIR/ADDITION ❑ (No septic tank or seepage pix;permitted if publ is sewer is;` 'aVailable within 200 feet.) Installation will serve: Residence Commercial _ Otherv.l ) Number of living units: ""--i— Number of bedrooms � -- Lot size Character of soil to a depth of 3 feet: ,��o j3 _ I Watei table depth fib___ a SEPTIC TANK Type/Mfg -�� i_ Capacity �,,�,— No.�ompartments '. ; PKG. TREATMENT PLT. Type/Mfg Capacity f Method of Disposal'�� SEWAGE SYSTEM DESTRUCTION Distance to.nearest: Well Foundation [ P operty§Line _ r � LEACHING LINE No. & Length of lines Total len6l0si"ae V16 P-711— FILTER BED ❑ Distance to nearest: Well Foundation Ila� jroperty Line 3 SEEPAGE PIT'S' FI Depth Size Number SUMPS Distance to nearest: Well Foundation tr: "'Property Line I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the workrill be done in accordance with San Joaquin county, ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i e Home owner or licensed agent's signature certifies the following: "I certify that in the perforWnce 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 followings "I certify that in the performance of the work for which j this permit is issued, I shall employ persons subject to workman's compenitsation laws of California." I The applicant must ca fo requ ed inspections Complete ddrawing rev&se:s .l1e. %Z- Signed ' k`+d Signed K . Title: �ClL� ' Date: L-51-15,_ F EPARTMENT USE ONLY r Application Accepted by 1. Area Q ❑ Stk 466-6781 E Additional Comments: % - - _ Lodi 369-3621 Pit or Grout Inspection by Ddte ❑ Manteca 823-7104 Final Inspection by bate ❑ Tracy 835-6385 Applicant - Return all copies to: Fnvironmenta ea 'th Permit/Services 1601 zelton Ave., P.O. Box 2009, Stk., CA 95201 'r t FEE BASE AMOUNT DUE AMOUNT REMITTED #RECEIVED BY DATE PERMIT N0. INFD Wfi. 3 I EH 13-24T REV. 10/82_ 'L = i a �� 10/82 500 .