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APPLICATION POR,PERMIT i " SAN JOAQUIN LOCAL HEALTH DISTRICT p.3 ' '= 0,5'— s 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT N0. Telephone (209)466-6781 DATE ISSUED 7_�__ 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 Joaquir County Ordinance No. 549 for sewage or No, 1862 for,well/pump and the Rules and Regul ions of the San Joaquin Lpcaj Health District, Job Address Subdivision Name Owner's Name Address Phon Contractor's Namejn��,��.;Vc..4caicense No. 329:2 Z (ca Phone 767—s10,57 TY .7,.�. PE OF WELL/PUMP WORK: NE6! WELD WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER r ? DISTANCE TO NEAREST: SEPTIC TANK "" SEWER LINES DISPOSAL FLO. PROP. LINE r. { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation ' `a U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well-Casing ` Public " �j Other Delta Type of Casing [`1 Irrigation* Approx. Eastern Cathodic Protection De th Specifications Depth o pf-Grout Seal+ Geophysical " ] Other �+•` f Type f,Grout k F ,Surface Seal Installed by Repair Work Done [] Type of Pump-"'- H.P.: State Work Done Well Destruction U Wel1,D'iameter Sealing•Material (top 50') Depth fFiller Material (Blow 50') . TYPE-OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION " (No,-septic tank or seepage pit permitted if public sewer is " f` �- j�available within 200 feet.) Installation will serve: Residence._ Commercial Other /. e.l `" t Number of Ii.v"ing'units: Number of ooms Lot size X—d2.-<'L �► Character of soil to a depth of 3 feetbed: Water table depth _.,,SEPTIC TANK Type/Mfg 1 ' Capacity No. Compartments y PKG. TREATMENT PLT. Type/Mfg Opacity Method of Disposal ) SEWAGE SYSTEM Distance to nearest:. Well F Foundation Property Line DESTRUCTION LEACHING LINE L-J.0—.N.6 --& Length,oklines I ` Total length/size ' FILTER BED olvw,- ,Distance to nearest:' Well a Foundation I -'rlProperty Line :: SEEPAGE PITS Depth _ 4 Size � Number d SUMPS El Distance to nearest: Well 1 Foundation �d -- }Property Line c4q"_ - DISPOSAL PONDS ' i I hereby certify that'I have prepared this application and that the work wilT 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 torwor"kman's compensation laws of California." I The applica ust cWllr required inspections. Complete drawing on reve s 'dSigned X Title: 'f i` a Date: F FOR.DEPARTMENT USE ONLY Appli ion "Accepted by � Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by Date V H" Tracy 835-6385 Applicant - Return all copies o:. Environmenta Health Permit/Services 16011E. azelton Ave., P.O, Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYd DATE PERMIT NC. INFO f 467 f EH 13-24 REV. 10/82 10/82 500 14-26