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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' y 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. `A—378 Telephone (209) 466-67B1 DATE ISSUED JA—S-FsLj 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 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 District. Job'Address T S.9uT�S GT• f��9/+lis ��r-»r� Subdivision Name Owner's Name I�OY /}�T.DMiX�9/YO Address 30944 x',_ i5l ui� Y-7rYAG Phone Contractor's Name -go, License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r--' _FOUNDATION .- AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS dQ I J Industrial [fOpen Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy" Dia. of Well Casing ❑ Public [j Other ❑ Delta Type of Casing ❑ irrigation Approx. Eastern Specifications Cathodic Protection Depthi Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work,Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence D( Commercial _ Other Number of living units: Number of bedrooms. ? Lot size / ticrr� l Character of soil to a depth of 3 feet: GA,e A o AM Water table depth SEPTIC TANK Type/Mfg die CAs Cyyr, 'Capacity j;0t ey No. Compartments , L PKG. TREATMENT PLT. F-1 Type/Mfg % Capacity Method of Disposal �T SEWAGE SYSTEM Distance to nearest: Well �'o' Foundation 0 Property Line /00-' DESTRUCTION LEACHING LINE No.No. & Length of lines �—9 a ` Total length/size -k (�{ FILTER BED ❑ Distance to nearest: Well 1061 Foundation 1 c' Property Line v 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 San 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, I shall not employ any person in such manner as to become subject to workmang 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 subject to workman's compensation laws of California." The applicant mus call for all required inspections. Complete drawing on reverse side, Date: 2 -10-,Fy Signed X Title: OR ARTMENT USE ONLY Stk 466-6781 Application Accepted by / Area _Aq .___— Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by op Date U Manteca 823-7104 Final Inspection by Date a L7 Tracy 835-6385 Applicant - Return all copies to: . EnvironmentalgWalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 111s�g Sc s 10/82 500 EH 13-24 REV. 10/82 14-26 I