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APPLICATION FOR PERMIT ` `0v SAN JOAQUIN LOCAL HEALTH DISTRICT I.WQ _ JL c + 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NOA ;L 7w Telephone (209) 466-6781 GATE ISSUED W 2_— 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 workherein 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 theSan Joaquin Local Health District. Job Address .2. 73 IyI N ILJ 9V 5;01 Ca 50IMSA7 Subdivision Name Owner's Name ilSI�:K CRANE, 1-0)C_ Address 13,11 n41a"✓t19CSA 1217 MN PL' Phone q_y_,)63 Contractor's Name - SAME - License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial E)Open Bottom F1 Manteca Dia, of Well Excavation j1 Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing 17 Public Ej Other Delta Irrigation Type of Casing U 9 Deprox. Eastern Specifications F-ICathodic Protection Depth Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction U Well Diameter Sealing Material (top SO') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 6/75 c. �S-A r`w �'v ee�ble within 200 feet.) Installation will serve: Residence Commercial Other / W Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ST_ Type/Mfg Capacity •7pr0 '?yad No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Septic Tank d Distance to nearest: Well �j.f Foundation /G Property Line le 7� Destruction LEACHING LINE 6?j- No. & Length of lines ar r Total length/size FILTER BED r_1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS (jD� Depth �A S v Size Number W SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ccvli� !(de 3- 70i A< L..-u T //d'al'«.+ 7`tf �r 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 agent's 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 workman 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 shall oy persons subject to workman's compensation laws of California." The applicant must 11 quired inspections. Complete dravi on rever a side. Signed X - Title: Date:/2--3 2 Application Accepted by .F $DE ARTME T�t1SE ONLY Area 474/ Stk 466-6781 T TT L 171 o'u � Additional Comments: Lodi 369-3621 �)ys'T--/?-fL 2+? Pit or Grout Inspection by - - 3 Date Manteca 823-7104 &o' {s.✓ Final Inspection by �- Date 416./8-57 Tracy 835-6385 42-/✓-d Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av P.O. Box 2009, Stk., CA 95201 rINFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �(X 4 `1Yl Ia131�'�- ��-7�S EH 13-24 REV. 10/82 .{�� 14-26 �j ,-7-�-- I 1 _ 10/82 500 I �/�-'t-� L