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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �Q Telephone (209) 466-6781 Y . 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 workherein l described. This application is made incompliance with San Joaquin"County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address (Q �fQ�Lr//1 .6 Subdivision Name G Owner's Name u,:,riZA.1 . Address &a V, LAA AGM /?,Q, &9p f Phone A61--23 VZ cA j Contractor's Name 9=. Woo 2�, License No. �l.+r�7( Phone TYPE OF WELL/PUMP WORK: NEW WELL ww �. WELL REP LAC EMENT+.[� DEST_RUCTION..rJ .,., GIs.. . - . . s�+wM.- PUMP INSTALLATION ❑ SYSTEM REPAIR 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 17 Industrial U Open Bottom + [:,Manteca pia. of Well Excavation {� L7 Domestic/Private Gravel Pack 0 Tr ca y Dia. of Well Casing Public OthE�r [� Delta Type of Casing V FI Irrigation .•"""Approx. Eastern Cathodic Protection�' Depth Specifications Geophysical Depth of Grout Seal Type of Grout Other" " y,,,✓ � Surface Seal Installed by Repair Work Done Type of Pump H.P. 1, .O State Work Done �! Well Destruction (J Well Diameter Seal ing'Materialor(top 50') Depth Filler Material (Below50') TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is r f available within 200 feet.) Installation will serve: Residence Commercial Other R AN-11 �� Number of living units: _ Number of bedrooms — Lot size# ZOpp 2�X Character of soil to a depth of 3"feet: e�::Q 4/ Water table depth y ,(r,f �r 'SEPTIC TANK j j Type/Mfg 4-1- ee. edp Erge Capacity _. No. Compartments 1- PKG. PKG. TREATMENT PLT. Type/Mfg "F 3 Capacity Method. of Disposal Distance to nearest: Well Foundation _ Property Line 910 LEACHING LINE No. & Length of;lines`_ Total length/size 17a FILTER BED Distance to nearest; Well_-,e4g�Pf Foundation 3 Property Line K SEEPAGE PITS DepthSize _ `0 Number ::2— SUMPS SUMPS ❑ Distance to nearest. Well /_:�O Foundation 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 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." The applicant must call for all required i spections. Complete drawing on reverse side. Signed X , - Title: e. Date: 7— FOR P RT USE ONLY Application Accepted by &LAtn4z _ Area Stk 466-6781" Additional.-Comments: P` � x ❑ Lodi 369-3621 Pit or-@F69&-inspection by iP' C Date //, �-' � Manteca 823-7104 Final Inspection by � Date //� 4i Tracy 835-6385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFD " EH 13-24 REV. 10/82 10/82 500 "": 14-26 ""