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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH RISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 0.66=6781 DATE ISSUED -o2�r0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicat(i)" ' 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 JoaquiLocal Healt;}I istrict, .d am Z �� Job Address r�' •i , _ ubdiv;Awia Name Owner's Name _ Ad ress sX_ > � s wa, 1!a'If'tti ��"� Phone' --4_0 73 Contractor's Name 'i?Tt� �f�F`f � :�GQ,F License No. ;ZJ-V- 4-3 Phone -elyf "C7c=,9 i _ I TYPE OF WELL/PUMP WORK: 4NEW.WELL ❑ �\WEL-L REPLACEMENT Q ,<` %DESTRUCTIR[1, , PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP$ f INTENDED USE TYPE OF WELL s:.,'PROBLEM AREA. CONSTRUCTION SPECIFICATIONS Industrial Open Bottom ,,:.,,:PROBLEM. }Q Manteca w { Dia. of Well"Exca�vation- jJ Domestic/Private ❑Gravel Pack, r rJ Tracy °; Dia, of We11 "'Ca'sing� Public F-1 Other Delta Type of Casing LjIrrigation Approx'. Eastern Specifications � 1 Cathodic Protection Depth Geophysical Depth of Grout Seal ( ❑Other a Type of Grout h R Surface Seal l Ihstaled by 1. J Repair Work Done Q Type of Pump { H.P. State Wor*Done ,f V l F Well Destruction F-1 Well Diameter f Sealing Material (top 50') � Depth Filler Material (Below 501-)-. TYPE OF SEPTIC WORK: NEW INSTALLATION U, REPAIR/ADDITION'X-, (No septic tank or seepage pit permitted if public sewer is ' �• ` ! �, available within 200 feet.) Installation will serve: Residence Commercial Other �4 Number of living units: -Number of.bedrooms 3 _%Lot`size AVO )e Z Character of soil to a depth'of 3`feet: •CL1 i %Z Water table depth /�f SEPTIC TANK Ej Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM t`,* Distance to—nearest: Well Foundation Property Line 3 DESTRUCTION XI.❑ LEACHING LINE ( No. & Length of lines wy7� -;,Tata1 length/size FILTER BED Distance-to nearest:"*Well #'�G r Foundation �� Property Line SEEPAGE PITSNumber Deeth _ k SUMPS Distance to nearest: Well /'O D Foundation t9 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 Lqcal 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_empl.oy any-pers on_in_such-manner as_to-become_subjgct 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." The applican st call for1 eq fired inspections. Complete drawie�n rev,erse side. Signed Title: 4 Date: /X23 _ f R DEPARTMENT U NLY _ Application Accepted by �Ij Area — [] Stk 466-6781 Additional Comments: „ .JiA ' Lodi ' 369-3621 Pit or Grout Inspection by Date'a El Manteca 823-7104 Final Inspection by' ' Date 1 Tracy 835-6385 Applicant - Return all copies to: EnvirKRKntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT AMOUNT REMITTED RECEIVED.BY """DATE' PERMIT NO. INFO End EH 13-24 RIiV. 10/82 1 10/82 500 14:-26 t .a