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t APPLICATION FOR PERMIT-_' SAN JOAQUIN LOCAL HEALTH DISTRICT Cs 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ' '93`J . Telephone (209) 4.66-6781 �. PERMIT EXPIRES-1 YEAR FROM-DATE ISSUED DATE ISSUED �3 (Complete in Triplicate) I 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 and Regulatio`hs of thh San Joaquin Local Health District, Job Address �, ! Owner's Name //�-� ,,�� D' Subdivision Name �� _ r`� Address Phone Contractor's Name /�•42�5 Zd�- License No, Phone �za TYPE OF WELL/POMP WORK: II NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [� DISTANCE TO NEAREST: SEPTIC�'TANK SEWER LINES DISPOSAL FLD. PROP. LINE 01.1 x 4 FOUNDATION AGRICULTURE.WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t Industrial ❑Open Bottom [] Manteca Dia, of Well Excavation Domestic/Private 0 Gravel Pack ❑ Tracy Dia, of Well Casing ' ❑ Public El Other ❑ Delta Type of Casing F1 Irrigation Approx. ❑ Eastern []Cathodic Protection I' Depth Specifications ❑Geophysical Depth of Grout Seal j❑Other 'i Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump 14.P. State Work Done Well Destruction F-1 Well Diameter Sealing Material (top 50') ' Depth �� Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION '- REPAIR/ADDITION LI K) (No septic tank or seepage pit permitted if public sewer is ) Installation will serve: Residence � Commercial Other available within 200 feet, � Number of living units: Number of bedrooms Lot size rT � 7 K 'Ot7 Character of soil to a depth of 3 feo; Water table depth SEPTIC TANK Type/Mfg Capacity,/ Zop No. Compartments V j PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to Weareski W tl I ZZI� Foundation Property Line Z a LEACHING LINE ❑ Nod & Length of lines Total length/size FILTER BED 0i`stance to nearest: Wel Foundation - Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 agentEls 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 workmant compensation laws of California." Contractors 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 su ject to workman's compensation laws of California," The applicant st ca9T f r all req d ins c i . Complete dra�2oLverses e. Signed x I� Title: Date: R RTMENT USE ONLY Application Accepted by fr Area 5tk 466-6781 Additional Comments: F� Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date (-Z-S-43 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ServiCeSr 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE aAMOUNT DUE AMOUNTE:d REMITTED RECEIVED BY DATE PERMIT NO. J INFO + 3 9,3 5.5 aE EH 1 -26 ��. B2 ,Lo.�3r �:,il�wr � Gh PraV+v► }'7,, uV�;r��fOh7 10/82 500 64c/CJi'G�[ r//c�n.11 �ii�he 4 f,✓cll �'�a 1744i;7(l,r J7,6YW-