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APPLICATION FOP, PERM:7 SAN JOAQL,.'. LOCA- M,411H ;:STRICT [[ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I Telephone (?09) 466-6781 ��L_/ � 2 DATE ISSUED�/�.� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �— (Complete in Triplicace) 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. 1 Job Address �Z /�///NFoK,o Subdivision Name ` Owner's Name 13i/I /c74c/GLzev Address .Sgre Phone Contractor's Name . /�f}2q/-y r,.. License No. �3y--T I, Phone LTYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ GJ PUMP INSTALLATION SYSTEM REPAIR OTHER LI , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE L — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L11 Industrial U Open Bottom F1Manteca Dia. of Well Excavation L_I Domestic/Private F-1Gravel Pack Tracy Dia. of.Well Casing Public 7J Other Del to Type of Casing L Irrigation Approx. Eastern Ej Cathodic Protection Depth � Specifications < Depth of Grout Seal Geophysical Type of Grout r, i (Other Surface Seal Installed by LRepair Work Done F-1Type of Pump H.P. State Work Done (y Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') L TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.4DOITION �T (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other L � ii Number of living units: Number of bedrooms _ Lot size Character of soil Co a depth of 3 feet: Z.�}y Water table depth SEPTIC TANK �C Type/Mfg [ ,4,c, Capacity / 2.civ No. Compartments 2 PKG, TREATMENT PLT. EJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines S Z/O / Total length/size V 7 0 X' 2.._ L FILTER BED Distance to nearest: Well /0c, Foundation -- Property Line — SEEPAGE PITS Kj Depth 2 S Size '3—5 Number SUMPS Distance to nearest: Well /0 c, Property Line _ { DISPOSAL PONDS LI 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-t+,e-9" 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 workman4 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 persons subject to workman's_compensation laws of California." The applicant must ccaaj1 ffor a requi d�insp ctions. Complete drawing on reverse��!s e. Signed % C�F(,,f' Title: 7'i�+zvt Date: 7—s--&3 ` Application Accepted by (��pARTMDT USE/OY Area Stk 46fi-6781� tr iAdditional Comments: Lodi 369-3621 ` Pit or Grout Inspection by Date 7 S-40 Ll Manteca 823-7104 Final Inspection by Date Tracy .835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952111 FEE BASE AMOUNT DUE I AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO `f Is oo -7 ` EH 13-24 REV. 10/82 10/82 500 14-26