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APPLICATION FOR PERMIT fti SAN JOAQ60' LOCAL HEALTH DISTRICT tt 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, p-p 3-1 Z7 1, Telephone (209) 466-6781 1 PERMIT EXPIRES 14YEAR FROM DATE ISSUED DATE ISSUED 1 (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 nd//Regu�la`tiions of the San Joaquin local Health District. Job Address b vel a^ quSubdivision Name Owner's Name �( A\'Z)NA% i enss Phone I Contractor's Name � _E,�, �� Mi No, � 7s d �� Phone TYPE OF WELL/PUMP WORK: NEW WELL 0 WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR OTHER l DISTANCE TO NEAREST: SEPTIC TANK v a Y.�.' �i LJ SEWER.LINES Y.// 1 DISPOS,ALFLD.._ P OP, LINE xFOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS i l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r If Industrial E] Open Bottom Manteca Dia, of Well Excavation ❑ Public Domestic/Private ^(-Otheel Pack Tracy �.•O�a, Of Ne11 .Casing Delta LI Irrigation ❑ Type of Casing Approx. Eastern ,.Q Cathodic Protection DepththSpecifications Geophysical Depth of Grout Seal ` {❑Other Type of Grout ' - r Surface Seal Installed by Repair Work Done (]�r H.P. State-Work Done 'Well Destruction tJ,' Well Diameter Sealing Material (top 501) Depth ` Filler Material (Below 50') .y . 'f TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/AODITION U (No 'septic tank or seepage pit permitted if public sewer is ��^^^ available within 200 feet,) Installation will serve: sidence _ Commercial Other Number of 9i4'ing units:— "� Number of bedrooms Lot size Q 3(�d r r+ Character of sail to.a depth of 3 feet: _�h% Water table depth _ SEPTIC TANK - { �, Type/Mfg C hNJ r, -rF Capacity No. Compartments p� t � . PKG. TREATMENT PLT:� Type/Mfg- Capacity Method Of1 Disposal �1SEWAGE•SYSTE ( Distance to nearest: Well ()r Found tor, Property-Line Property-Li ' DESTRUCTIOMr N ❑ ( ^} ( LEACHING LINE-`"'4 f No. �Leng�of'yines Total length/size F 7 ^,< FILTER BED „ f❑ Distance to nearest: Weil © pundation Property Line FT ' SEEPAGE PITS r i r.. Depth Size Number ( r SUMPS , Distance to nearest: Well Foundation 'Property Line DISPOSAL PONDS ; I h reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county „oydinadces, stat(e laws, and rules and regulations of the San Joaquin Local Health District. f Home.,owner or licensediigent's signature certifies the following: "I certify that in the performance of the work for which this permit As 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 : ermil^is issu , I shall �@mploy persons subject to workman's compensation laws of California." , +The a 1 C ca 1^fqc all Req n redo nspections. Complete dFawing o reverse ide. i�Signed 1�1 L 11 Title: 1/- � Date: 7 lQ e-?r !1 F FO DEPARTMENT USE ONLY 1 Application Accepted by , :Area Stk 466-6781 + Additional "I'm ts: — 1 O r 7111 < < C+•fitl.. Lodi 369-3621 Pit or Grout [ns ecti n ` p Date � Manteca 823-7104 Final lnspecti0n by ✓ Date 3 D Tracy 835-6385 Applicant - Return al_lr'co a to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! FEE BASE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT N0. 1 INFO r 1 L4 S I ---M3 i a ?3 134.2-7 ._.__._._ y` EH 13-24 REV:10/!;2 - _ 0/82300 ^...t.