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K i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL;HEALTH�DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA.. PERMIT NO. Telephone.(209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 I and the Rules an Re 1 t' of the San Joaquin Local Health District. Job Address , W000 WARD RV t Subdivision Name E Owner's Name mck L.00m4g Address Phone ,317 22C8 Contractor's Name '%M '-CAJZ(m�Lli License No. —2,(437113 Phone �2�4SBg/ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE'TO NEAREST-' SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE '7 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 17 Industrial ❑Open Bottom r„f]Manteca Dia. of Well Excavation I U DomesticlPrivate ❑Gravel Packl ❑ Tracy Dia. of Well Casing ; ❑ Public ❑Others ❑Delta i Irrigation 1 Type of Casing U g Approx. ❑ Eastern Specifications i ❑Cathodic Protection Depth Depth of Grout Seali 1 ❑Geophysical ❑Other Type of Grout `r 1 Surface Seal Installed by 1 Repair.Work Done Qi Type of Pump H.P. State Wor Done Well Destruction ❑ Well Diameter1 Sealing Material (top 50') Depth I N Filler Material (Below 50') . TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR ADDITION ✓, U. / �(No septic tank or seepage pit permitted if public sewer.is .:. I available within 200 feet.) ' Installation will:serve: Residence _�Commercial _ Other Number of living units, :Number of bedrooms 3 Lot size Character of soil^to a depth of 31feet; SA-V o /Water table depth d+ SEPTIC TANK ❑ Type/Mfg FIZeCALM Capacity 1/2 OV r f No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg T ? YP 9 ,- �]f Capacity ,.� Method of Disposal SEWAGE SYSTEM Distance to nearest:' Well _�` Foundation 0�,� Property Line s s DESTRUCTION C] LEACHING LINT No.-& Length of lines 3 - 0 _ Total length/size FILTER BED ❑ Distance�.toFnearest: Well Foundation .f Property Line SEEPAGE-PITS Depth Size Number SUMPS IJ Distance io nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ R 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 workmant 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 p sans subject/to workman's compensation laws of California." The applicant call pfor 7 requir inspections Complete drawing on reverse side. p Signed X >t IL f Title: C+"W- I Date: I �� s FOR A MENT USE ONLY } Application Accepted by - s ,�� T Area 1-3 ❑ Stk 466-6781 AdditianalComments: a VManteca = 369-3621Pit or Grout Inspection by F 1 Date 823-7104 Final Inspection by _ Date y 835-6385 f Applicant - Return all co to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a � ; t -FEE-4—BASE- —AMOUNT--,DUE-1—AMO'UNT�REMITTED-1 —RECEIVED-BY — --DAT£ �--PERMIT-NO. -_^--�----�^-= INFOO _ uT EH 13-24 REV. 10/82 C� � �`+� A 10/82 500 14-26 A ?'