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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HFA.LTH JiSTRICT q 1601 E. HAZELTON AVE., STOCKTON, .CA PFRMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE 3SSUEO (Complete in Triplicate) f Application is hereby madJto the San Joaquin Local Health District fora permit to construct and/or install the work herein j described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or NO.'1862 for well/pump f and the Rules and Regulationsj of the San Joaquin Local Health District. + Job Address �•? .,�,,1/1�i�4�EQt �"TJ�,/V Subdivision Name Owner's Name do*w +. Address ZZ IsTly r n �Jose C4 Phone `�lrsS-gA�+�. Contractor's Name .— License No. 3 Phone TYPE OF WELL/PUMP WORK: NEW IWELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR U OTHER J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE.WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ((� Industrial [JOpen]Bottom Manteca Dia. of Well Excavation J Domestic/Private + F_j Gravel. Pack ❑ Tracy Dia. of Well Casing Public Other Delta x ❑ ❑ T L_ilrrigation 'Approx. Eastern Yof Casing Depth Specifications ifications F-ICathodic Protection p Depth of Grout Seal Geophysicalr v 1 , . � � Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done S Well Destruction U Well Diameter Sealing'Material (top 50') I t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLA7ION'X REPAIR/ADDITION fJ (No septic tank or seepage pit permitted if public sewer is i ' available within 200,feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Z Lot size W-)( 1 2-7 � R Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK Z9 Type/Mfg Capacity J/ Q_- No. Compartments Z PKG. TREATMENT PLT. Type/Mfg Capacity Method' of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line s DESTRUCTION ❑ LEACHING LINE No. & Length of lines- Total length/size otLr 3[ 3 9 , X /210 FILTER BED J Distance to nearest: Well Foundation Ito Property Line SEEPAGE"PITS Depth S Size 3 3" Number 3 } I SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 workmanS compensation laws of California." Contractor's hiling or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, F sha employ rsons ject to workman's compensation laws of California." ` Thea lic 11 fo all re r d iJ 1 pp pec ion , Comple r g on reverse side. .«.... Signed X itle: Date: ea _3� DE ARTME 4T SE ONLY s Application Accepted b Area d E] Stk 466-6781 .a Additional Comments: -� mLodi 369-3621 Pit or Grout Inspection XDate �9 TJ 3 U Manteca 823-7104 Final Inspection by Date &?d- J?3 L7 Tracy 835-6385 Applicant - Return all copies t :;.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0.- Box 2009, Stk., CA 45201 FEE BASE AMOUNT DOE AMOUNT REMITTED. RECEIVED BY DATE pp q PERMIT NO. INFO 0 50 ; EH 13-24 REV, 10/82 10/82# � 1 14-26 F t �