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APPLICATION FOR PERMIT SAN JCAQUIN LOCAL HEALTH GiSTRICT 1601 E. HAZELTON AVE.,, STOCKTON, CA PERMIT N0. q f Telephone (209) 466-6781 , 7 DATE ISSUED / U 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 it compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump { and the Rules and Regul ions of the San,Joaquin Local J It istrict. y Jab Address division Name 421 Owner's Name Address d taV1 VPhone Contractor's Name /0,*Pp4./� � SrD P License No. Phone Wim,-9 :)— TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR j OTHER'Ley. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. S4 — PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS lJV AINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F f, ❑f Industrial U Open Bottom E] Manteca Dia. of Well Excavation E i ❑ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing e Public �'., �j Other ❑ Deltaw•` t Type of Casing LjIrrigatiori� Approx. Eastern * - '' Specifications C Cathodic,ProtDepth `ection Depth of Grout Seal Geophysical Type of Grout 4 AoR LJ Other £�. Surface Seal Installed`by ! -Repair Work Done El Type',;f Pump� " �� H.P. State Work Done � P I ! Well Destr.uction.0 Well Diameter Sealing Material {tap 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATIONREPAIR/,ADDITION J :(No-septic tank or seepage pit permitted if public sewer is T' - r - s, c available within 200 feet.) Installation will serve: Residence Commercial Other ' �� Lot size 'k- ` r Number of living units: Number of bedrooms .z. Water table depth 4�O Character,of_-soil_to a depth of 3 feet: SEPTIC TANK, Type/Mfg. „-°Capacity No. Compartments kMethod of Disposal PKG. TREATMENT'PLT ,,,Type/Mfg .k - Capacity p a SEWAGE SYSTEM Distance'to nearest: Well' ^Foundation ��l`3� Property Line Zoe DESTRUCTION ❑ s'. LEACHING LINE No. & Length of lines Z Total length/size' f7 , FILTER BED ❑ Distance tonearest: °Wel l• Foundation =- Property,Line SEEPAGE PITS Depth _, Size ` I -O � Number• 7�=" SUMPS �� Distance to nearest: 'Wel-]-'rte Foundation � "� _ Property Linef ^ . 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 Iand 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' issue I shall not employ any erson in such manner as to.become subject to workman§ compensation laws of California." Con tractdr's ing or sub-contractin ' nature certifies the fallowing "I certify that in the performance of the work for which this ISe`rwit issued, I shall emplo rsons subject-to workman's compensatjon laws of California." The app Iic al.l-f all re ed ins ctions.VkComplel�,e on reverse side. r. Signed Title: 1 Dater b F�'R ART NT USE ONLY Application Accepted by e/ ,r; A ea �f 5tk 466-:6781-.1-- + `+ °A z x r- �, Lodi "" 369-3621. Additional Comments: �—1 i y 1Pit or Grout Inspection by bate Manteca823-7104 Final Inspection by �+ Date p`1"a` racy 835-6385 Applicant - Return all copies to: �"�Envi o mental. Healt6-P,:mit/ erv,'ces 1601 E, Ha261f6 Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE E AM�UNT REMITTED y� , s RECEIVED BY y DATE 'Q PERMIT NO. 4 AMOUNT DU INFO titi 1 u r-Zs a y o S i i L 10!82 500 EH 13-24 REV. 10/82 y. `' 14-26