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s. APPLICATION FOR PERMIT t SAN JOAQLI!; LOCAL 'riEALTH DISTRILT 1501 E. HA7FLTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 465-6781 GATE ISSUED i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I I (Complete in Triplicate) Application is hereby made to'the San Joaquin Local Health District fora 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 Joaquin -Local. Health District. Job Address F {IVB Subdivision Name 5-6 Owner's Name MCI��C e,.1 V�>fly� . .Address Ayelf Phone Contractor's Name J� 61L- License No. / Phone '1 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑} OESTRUCTIDN ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK{{ SEWER LINES DISPOSAL FLO. _ PROP. LINE FOUNDATION'1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO LEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing r� Public Other Delta ❑ [-j ❑ Type of Casing Lj Irrigation Approx. Eastern Specifications ❑Cathodic 'Protection Depth Depth rof Grout Seal ❑ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done [� Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'} Depth s Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ii<No or tank or seepage pit perm)ited,if public sewer is C available within 200 feet.) Installation will serve: Residence W;/ Commercial Other L,-.0 Number of living units: �'-� Numder of bedrooms _ , _ Lot size R(Ale^ Water table depth f"n Character of soil to a depth,of 3 feet: SEPTIC TANK FJ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM � DisLa�ce to nearest: Well PropertLine_ Foundation y - DESTRUCTION 3 O!� ._mow Total length/size o nu LEACHING LINE X No. & Length of lines -,kms FILTER BED ❑ Distance to n?„rarest: Well Foundation._ Property+Line ' SEEPAGE PITS [j Dept Size SUMPS �` Distance to nearest: Well Foundation/ Property'Line 4,f ' DISPOSAL PONDS ❑ .s ^ 1 I hereby certify that 1--have-prepared this application and that the worklwill be done in accor nce with 5a ,.Joaqui-11% y ordinances, state laws; and rules:and regulations of the San Joaquin :Local Health District.- Home owner or licensed agent's cer :f e'-s;£he_07.1owing'TAtert-fy'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 Califprnia." Contractor's hiring or sub-contracting signature certifies-the following "I certify that in the perfprmance of thea work for which this permit is issued, I shall[ -laws-person s.subject to`luorkman`'s"compensation laws-o f--Gal4ifornia." ' The applica ca11) all re fired inspections, Complate drawing on reverse side. + �/ Z_ C µTitle: pyE� Date: i Signed X � /� � DEPARTME USE wONLY y7-re6 a / ❑f Stk 466-6781 Application Accepted by/y Area 6 i. I `❑ Lodi ;369-3621 06 Additional Comments: '.1 �'e ,r Date , * , Manteca 823-7104 Pit or Grout;Inspection by~f-. f 835=6385 a 4 Date `L Tracy i Final Inspection by i Applicant -Return all copie t . nvironmertal Health-PermitLSe.rvices 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 r` REL,EIVED„BY DATE PERMIT N0. -- - »� FES BASE—AMOUNT—DUE4�: _...AMOUNT._.REMITTED..,.,..•„�., _ I k INFO ,� 10/82 500 LH 13-24 REV. 10/82 14-26