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F y E . EI ' APPLICATION FOR PERMIT SAN 3.OAQb1I! LOCAL HEALTH DISTRICT 16D1 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone {209) 466-6781 . DATE ISSUED ' 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 an CK/e ulation_s of the San Joaquin Local Hearth District. Jab Address ! UJ000VJAa0. Subdivision Name Owner's Name AL.Do R&_c14w% Address SAM4- Phone 3^ 62y Contractor's Name I im CA1Z&i0t License No. 3q 1�3 _ Phone212 6 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION € FF PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: kEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 11FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� Industrial U Opeh;Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing 17 PublicC1 Other Delta Type of Casing I ❑j Irrigation Approx. Eastern Specifications Cathodic Cathodic Protection Depth Depth of Grout seal } Geophysical Type of Grout �4 ❑Other Surface Seal Installed by ".a w Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction LJ IWell Diameter Sealing Material (top 50') iDepth Filler Material (Below 50'} O ' TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) ` Installation will serve: Residence x Commercial _ Other Number of living units: lJ �d�a�.�umtier of bedrooms' 3 .'� Lot size (� Character of soil to a ,depth_o.f}3 feet:• SA N Wate tab depth _ 1� s SEPTIC TANK s❑j Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT Q Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM "*� F-1 Distance to nearest: Well' t."o Foundation_,. .X-P.r_oper_ty-L ng i DESTRJCTION 7`- rte" / > LEACHING LINE No. &.;Length of'line5• -��.1�� A00J_rengtT`sE?ze S7-,F4�x Sre+n FILTER BED _3 Distance to nearest:Y Well 706-4 Fourdatioh '/4! Property jL"itle $` # L SEEPAGE PITS{ ❑ Depth 1 Stze- Number i SUMPS Distance to nearest: Well Foundation Property Line i r DISPOSAL PONDS C� y 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 rulesland regulationslrof the' San Joaquin,LOcal`H@dlthL,District. 4 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�5u6h manner asfto became subject to workmanl compensation laws of California." ' Contractor's hiring or sub-contracting signature certifies the*followl ng:L n.hcertify-tliat in the performance of the work for which this permit is issued, I sh1 e ploy persons subject to workman's compensation laws of California." The applicant t all for all required inspections. Complete drawing onreverse 'side� -� a r � ' " f q Signed X f/w+ -� f.., Title: �/"�� Date: FOR. E ARTMENT USE ONLY f_41 f E Application Accepted by i /� Area ❑ 5tk 466-6781 U� �f ; ! '�' Lodi 369-3621 } Additional Comments: - -e ❑ Pit or Grout Inspection t - `" Date Manteca 823-7104 Final Ihspecton by Date �� ❑ Tracy 835-6385 Applican G n d fcopi t EnvirV� o n Health Permit/� ices 1601 E. az`e ton. P. fox 20a9, Stk., CA 95201 a w--J�MOUAMGUNT„REMI,T_TED-______RECEI„ D„BY DATE PERMIT NO. INFO 10 YZZ, _xL4 EH 13-24 REV. 10/82 1 D/82 500 14-26 � � � .rte,.: Y!.i• ,