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r✓ APPLICATION FOR PERMIT r✓ SAN JOAQUIN LOCAL HEALTH DISTRICT �� JJ�O 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 work here 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 RegulaWnsof San Joaquin Local lth District. Job Address G Subdivision Name Owner's Name Address 2 ar7yy E J.AiJ[ Phone Contractor's I License No. Phone O� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '�' A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. �IttE f'A P (� FOUNDATION AGRICULTURE WELL OTHER WELL -Ff .Yfli"S '3TC�_u • V 1 J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l�0 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing Public ❑Other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ('n ❑Other Surface Seal Installed by Repair Work Done ❑ .Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') m TYPE OF SEPTIC WORK: NEW INSTALLATION �0 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence X- Commercial _ Other Number of living units: Number of bedrooms ;- Lot size /00 )1 1W Character of soil to a dep3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg )"ep-( f Capacity 1,200 No. Compartments _ PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Wellr Foundation Property Line DESTRUCTION LEACHING LINE No. 6 Length of lines _ /.l ,00 r Total length/size /00 FILTER BED ❑ Distance to nearest: Wel 10W 1#6I Foundation(,*j4/'r/61 Property Line SUS SEEPAGE PITS ❑ Depth Size ifik7 Number SUMPS ^ Distance to nearest: Wel l Foundation OV-le NO Property Line DISPOSAL PONDS ❑ -r7�- S `�v�q 1 5 n of rva r.4 ewO wiA I S�s°r-yp 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. $ 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 workmanS 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 pertons subject to workman's compensation laws of California." The applicant t call all required inspect s:- Complete dra g on reverse side. p Signed % Title: mi f Date: IL'L�,3 \ F DEP TMENT USE ONLY -wication cep ed by Area ❑ Stk 466-6781 Additional Comments-: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Cflc„ Date �—a��3 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Heiitth Permit/Services 1601 E. Hazelton Ate., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIkIlly DATE PERMIT NO. INFO _ ^^^ / � 3_7C^�O EH 13-24 REV. 10/82 O ✓�"l r�,L/ c�7��10//882 50.0 14-26 e� ! ,