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� r � ' 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISI • 1601 E. HAZELTON AVE., STOCKTON, CA PE8 "2.1983 PERMIT NO. . Oc/ tl / Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE lgg ELI _!(�!IgUIN LOCAL ATE ISSUED ' d —i�ALTH D1STRiCT (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 and the Rules and-Regulations of the San Joaquinn Low3 Health District, e. / ' Jab Address 3 92 !Z:0 e 4; A114lL lleG inydiw4eiaq."Myc=44�_ Owner's Name Z_ ��W_,4 ;QajJg&V3 Address ., . Phone _ Contractor's Name r?'f.�.dLR/E-�f License No. '.� O 4P3C74J4440,s _a Phone d9 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT EJ DESTRUCTION PL94P INSTALLATION SYSTEM REPAIR 0 OTHER E i DISTANCE TO NEAREST: SEPTIC TANK ( SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSLi INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS „QApen;Bottan _,443 Manteca.,, -.w^.. ^Sa.•�firNela;;Fxea4a41on'' - - -- •...+ 1,1 Domestic-/Private Gravel Pack Tracy Dia. of Well Casing P Public Ej Other Delta Type of Casing Lj Irrigation Approx. Eastern C]Cathodic Protection •Depth Specifications Geophysical Depth of Grout Seal 1! L3 Other Type Grout i Surface Seal.Installed by Repair Work Done [) Type of Pump H.P. State Work Done d, Well Destruction 17 Well Diameter Seating Material (top 5O') N Depth Filler Material (Below 501) __ ...... TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Installation will serve: Residence / Commercial Other Number of living units: .. j Number of bedrooms Lot size Character of soil �to ra depth of 3 feet: _S'{�+^moi Water table depth i'�' j SEPTIC TANK Type/Mfg enadc-4 PC, Capacity /,210 e No. Compartments PKG, TREATMENT PLT, Type/Mfg Capacity Method of Disposal i Distance to nearest: Well Foundation Property Line _ 1 - LEACHING LINE U No. & length of lines Total length/size I FILTER BED 0 Distance to nearest: Well Foundation Property Line l SEEPAGE PITS M Depth 1 Size Number. -•^r•SUMPS..�:.0:--Distance4to=nearest: "WellFoundation DISPOSAL PONDS ' I hereby certify that 1 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. 1 Home owner or licensed agent's signature certifies the following: 01 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 workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the w1urk for which this permit-is sued. I shall employ persons subject to workman's compensation laws of California." kv 1 The_appi3c\ant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: DEPARTMENT USE ONLY ( pplication Accepted by 14�''1encs� Area _ 0 Stk 466-6781 • Additional Comments: — Lodi 369-3621 ` Pit or Grout Inspection by Date Manteca 823-7104 Fina) Inspection by Date Tracy 835-6385 T Applicant - Return all copies to: Environmental lth Permit/Services 1601 E. HazeTfon Ave„ P.O. Box 2009, Stk.,,CF 95201 �b � i, INFO' BASE AMOUNT (DUE AMOUNT REMITTED ECEIYED BY DATE PERMIT NO. � 3 833 EH 13-24 REV. 10/82 ' ��- o�( a(� 10/82 500 14-26