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APPLICATION r0, PER•"'- SAN JOAQUII LOCAL .;cA 1 0 STRICT 1561 E. HA7ELT0I4 AVE., STOCKTON, CA PERMIT NO. ' Telephone (209) 466-57n1 ' DATE ISSUED — �/� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T (Complete in lriplica e) 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 Regulations of the San Joaquin Local Health District. Job Address _ Subdivision Name ' 1 Owner's Name { L 0ddress `2 i Phone _(rs�- �f`Z Contractor's Name^��f � ;� b., t� �License No. �C Z -- - -- ---„ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION El SYSTEM REPAIR j OTHER �� . OC7 DISTANCE TO NEAREST: SEPTIC TANK !S SEWER LINES DISPOSAL FLD. / 'I PROP. LINE 14D e �+ FOUNDATION TO AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ' ` (�, i_j Industrial ^'Open Bottom' "0'ManteCa """' Di-a of"We1T•Excavat5bh =�1„r,�t ' $fr-�c L1� O ti{� Domestic/Private Gravel Pack Tracy Dia. of Well Casing _ ale.- 17 ��_ 7��-- # 17 Public �Other ❑ Delta f L� LJ Type of Casing �p T a frj47 Gt� I Irrigation Approx. Lj Eastern Specifications ❑Cathodic Protection Depth — Depth of Grout Seal ( Geophysical Type of Grout e U Other r, Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work-Done fs Well Destruction U , Well Diameter Sealing Material (top _ i4 Depth Fila'er Materialow 50') TYPE OF SEPTIC WORK NEW INSTALLATION REPAIR/,ADDITION No septic tank or seepage it permitted if public sewer is � U U ( p P 9 P P I available within 20O feet.) Installation willlserve: Residence Commercial _ Other C Number of living units: Number of bedrooms Lot size Character of soil lto a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg pacity No. Compartments PKG, TREATMENT PLT..t] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION I LEACHING LNE u... No, & Length of li '`"r, _ Total length/size ~ _ f FILTER BED,' U Distance to n est: Well Foun ation 4Prpop�ekfy Line SEEPAGE PITS [} Depth Size Number l 5l{MP� Dista e to nearest: Well Foundation Property Line DISPOSAL PONDS c I hereby certify that I have prepared this application_ and,,/t work will be done yin accordance with San Joaquin county -ordinances, state laws, and-rules and regulations of the S'an Joaquin Local HeahtH District. Home owner or licensed agent's signature certifies-the following: "I certify that irk th l performance of the work for which this '.permit is issued, Iishall not employ any person in such inanner;as to become subject' to orkman� compensation laws of California." Contractor's hir'ingfor sub-contracting sigriatur,e certifies the following: 'I-certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant st cal l for 11 re d inspections.- Compll4te(drawing W reverse sii�de,,.nn,. �.. y� Signed X ? = Title �� r; �` lG/�3V:I1 alt �� Date: IL DET`M�E 5E ONCFY Applicatibn Accepted by y/ 'W4 Area-, �.C� ® Stk 5=fi781 Additional, Comments: �] Lodi Pit.or Grout)Inspection by � Date Manteca 823-7104 r-77 2 Final Inspection by Datel ='=' Tracy 835-6385 Applicant - Return ell copies to: Environmental Health P rmit/Services 1601 E. Hazelton Ave., P.D. Box 2004, Stk., CA 95201 FEE - BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO. EH 13-24 REV. 10/82 10/82 500 14-26 i