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4, 'i r APPLICATION FOR PIRI ' SAN JOAL7t,iN LOCAL H=BETH :iISIRICT �Q f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, a l� Telephone (209) 466-6781' DATE [55UE0-� PERMIT EXPIRES 1 YEAR FROM GATE ISSUEG (Complete;in,Triplicate) , Application is hereby made to thea an 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 Regulations of tfie San Joaquin Local Health District. Job Address f. ,��' Subdivision Name Owner's Name TV9 C.644 Al-A Address Phone I Contractor's Name jf} E, W,?p. License No. -Z f y 7f_ Phone C>cJ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION — " "`" PUh1rINSTALLATIONSYSTEM REPAIR- OTHER"U'" "" y DISTANCE TO NEAREST: SEPTICp,TANK _ SEWER LINES DISP05AL FLD. . PROP. LINE FOUNDATIONCn AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ..TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i IndustrialT- U;Open Bottom F-� Manteca Dia, of Well Excavation Domestic/Private t U �Gravel Pack Tracy Dia. of Well Casing Public r { �j Other Delta Type of Casing ! i . L Irrigation Approx. Eastern Specifications Cathodic Protection Depth ; — Depth of Grout Seal E] Geophysical LJ Other Type of Grout t Surface Seal Installed by+ Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') d Depth Filler Material (Below 50') TYPE OF,SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is ¢� / available within 200 feet.) r- Installation will serve: Residence _✓ Commercial Other Number of living units: Number of bedrooms. Lot size 1.<0 Al Q Q Character of.soilLLto a depth of 3 feet: L'L��, Water table depth SEPTIC TANK Xyt t g� 6 ` 1 Capacity No. Compartments PKG. TREATMENT PLT. Typ"e/Mfg Capacity Method of Disposal a j SEWAGE SYSTEM ' Dist pce It nearest: ell Foundation / Property Line l DESTRUCTION t JLf L L.( L(I A t/�+ a ' LEACHING 'L'INE No. &�L�of lines !— Total length/size �y��.�a.' FILTER BED Distance'to nearest: We11 Foundation ,-Q Property Line .1�If t,;a, SEEPAGE PITS Depth Size E _ �� Number G SUMPS Cistance.to nearest: Well Foundation p Property Line 7.S 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 a'gent's signature certifies the following: "I certify that in the performance of the work for,.which this permit is issued, I shall employ,any_person in such manner as to become subject to workmant 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." i The applicant must call for 1l required insDections. Complete dr wing p reverse side. Signed X= Title: t Date: &-247-P-3 I T NT U NLY ReplicationAccepted b;4Area42 3- Stk 466-6781 Additional Comments: } L] Lodi 369-3621 Pit or Grout Inspection b r Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all cop es t . _ Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2004, Stk., CA 95201 FEE BASE AMOUNT D'UE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO to 2c7 X33-sGa � EH 13-24 REV. 10/82 10/82 500 14-26 ttt