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f' 's APPLICATION FOR.rPERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON-AVE., STOCKTON, CA PERMI-1r N0. Telephone (209) 466-6781 . DATE ISSUED ,.+�"" �- 1•''^: . 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 i and the Rules and Regulations of the San Joaquin Local Health District. j ,lob Address 33-7 'PAC-IFrc 6e4- subdivision flame s Owner's Name �/C �4�-� Pi- _ Address Phone�Z 3-� 3 o4 1 Contractor's Name 19 License No. �� Phone 1 , Y TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ 63) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q l 1 DISTANCE TO NEAREST: SEPTIC TANK ;{ SEWER LINES DISPOSAL FLD. PROP_ LINE r ._ . FOUNDATIONS E1 AGRICULTURE WELL OTHER WELL PITS/SUMPS i OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS eINTENDED-USE TYPE ' ❑�Industriah� I'Open+Bottom-^~[]'Manteca fDi'a:,;of-Well-Excavation - ❑ Domestic/Private 0 Gra.veloPack . []Tracy Dia. of Well Casings r« .t ) Pubj 'c Other Delta ❑ ❑. ) ❑ ,Type.,of•Casin9i LJ Irrigation Approx. ❑ Eastern Specifications ) + Cathodic Q otection Depth ❑ _ , c Depth of Grout Seal . Geophysical Type of Grout LJ Other _ Surface Seal Installed by State Work Done - Repair Work3Done '❑. Type-of-Pump ""'�-°� P• - lWel-1 Destruction ❑ -Well Diameter —Seal liing-Material (�to�p 50') - w �r -_Oepth_ "' - """ "9`�Filler Material (Be�lo ')'�w,50 = . TYPE OF SEPTIC WORK: NEW INSTALLATION F-1REPAIR/ADDITI6N, (No septic-tank or seepage pit permitted if public sewer is :� available within 200 feet,) . Installation will serve: Residence commercial Other " Number of 1 iving units: Z ` Number of bedrooms_ . - - - Lot"size 1 Water table depth �� l 1 tr Character of soii tofa depth of.3 feet C� - 1J ❑ Capacity No. Compartments SEPTIC TANK Type/Mfg / ? f PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal }' -s t -+ � o SEWAGE SYSTEM' Distanc� -to nearest: We),lc Foundation �,. -, �.�,wPrert- P Y Line DESTRUCTION f �'*.. � ` LEACHING LINE � No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well 75�+,�Foundation /PJ r Property Line t ' Number SEEPAGE PITS ❑ Depth Size i x �� Foundation /Q r Property Line Well SUMPS Distance to nearest: - , # '< DISPOSAL PONDS ❑ , f f I hereby certify that I have prepared this application and that-the.-work_Ail I_ be.done in accordance with aSan 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 fn�the performance of 'the work for wh ch.this' permit is issued, I shall not employ any person in such manner as to become subject to•�orkman� 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 i issued, 1 shall employ person subject to workman's compensationlaws of California." , - , ' The appl i a m t call f all r re Pett ns. Compl to ng on reverse side. d;-Signed-X-- - - - =T+tl-e._ �A� j�� -Date: a RTMENT US NLY !. /� [] 466-6781 ; Application Accepted by AreaStk ' _ ❑ Additional Comments: : Ly L Q Lodi 369-3521 �"�'- ' -TI Pit or Grout Inspection by '"` Date Manteca 823-7104 i E Final Inspection by Date ��t -� --] Tracy 835-6385 t P•'�' k Applicant - Return all copies to: .En isronmen:tal It ermit/services 1601 E. Hazel onAve., P.O. Box 2009, Stk., CA 95 01 FEE BAS£i fit`-AMOUNT OUE _ `AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1 10/82 5001 EH 13-24 REV. 10/82 14-26 --�