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i APPLICATION FOR PERMIT { SAN IOAQLi`; LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT N0. 73-3 3 f Telephone (209) 466-6781 DATE ISSUED 13 PERMIT EXPIRES I 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 F, and the Rules and Regulations of the San Joaquin Local Health District. i` Job Address 27 y/ �/CA l MAR Subdivision Nim= Owner's NamePh 59 1j�,Z�j Address /. an Contractor's Name A, !_: (14 1-4-re- License No. fj j 3` Phone -0a !K�J I� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , + PUMP INSTALLATION ❑ SYSTEM REPAJR ❑ 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 JlN t I❑ Industrial ❑Open Bottom ❑ Manteca _ Dia. of Well Excavation - U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing t �] Public ❑ Other ❑ Delta Type of Casing Irrigation- w " . Approx, Eastern e th � Specifications . i~ ❑ Depth Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout FJ Other Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done, Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is - �_.. _,T b..=-.ava.ilabae withi-n 2J)O feet.^) �_�- Installation will serve: Residence �CammercialT-- Other Number of living units: Number of bedrooms _'Lot size ° —4—r I` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 7�-L _ Capacity __ No`Compartments PKG. TREATMENT PLT. ] Type/Mfg T Capacity ' Method of Disposal SEWAGE SYSTEM �-1 Distance to nearest: Well Foundation Property Line DESTRUCTION 2 LEACHING LINE ❑ No. & Length of Sines `r 'Total length/size �o � FILTER BED ❑ Distance to nearest; 'Well Foundation Property Line SEEPAGE PITS ' Depth Size Number ' SUMPS L1 Distance to nearest: Well Foundation Property Linef DISPOSAL PONDS ❑ - i 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 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 subject to workman's compensation laws of California." F The applicant must call r 11 re fired inspections. Complete drawing on reverse side. ( Signed X Title: .t�J Date: DE A NT USE ONLY Gam//1 _.. . Application Accepted by,- Area �' Lam- ❑ SLk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by" '` Date - ❑ anteca 823-7100.- , Final Inspection by Date — K racy 835-6385 { Applicant - Return all copies to: Environmental �Ith.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F E�EFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. IN r ' 10/82 500 EH 13-24 REV. 10/82 . 14-26