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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT dam{ q[7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. O,!-I/"'1 2, Telephone (209) 466-6781 . DATE ISSUED �I zrJ _g3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) b0 Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein W 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 ie Sad•Joaquin Local Health District. Job Address / Subdivision Name Owner's Name Yr Address r_X - ?iLL�ra�t.K-�s� Phone Contractor's Name License No. $6 i5.7A ( • Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ ( " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA f CONSTRUCTION SPECIFICATIONS I� Industrial ❑Open Bottom Manteca .s Dia. of Well Excavation ❑Domestic/Private ❑Gravel Pack ❑Tracy i Dia. of Well Casing ❑Public ❑Other ❑Bel to Type of Casing F] Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done `" 1 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material-(Below 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION &r-Mp septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence e_/ Commercial _ Other _ Number of living units: I Number of bedrooms _ Lot size - s O I P Character of SD11 to a depth of 3 f/ee1�t: y *&4 (o A-i-_ Water table depth SEPTIC TANK [ ' Type/Mfg (as B +g Awl Capacity- No. Compartments 2.- PKG. TREATMENT PLT. ❑ Type/Mfg - Capacity Method of Disposal 0 SEWAGE SYSTEM Distance to nearest:Y WelI �_ Foundation .Z$--S Property Line DESTRUCTION " LEACHING LINE No. 8 Length of lines Total length/size FILTER BED BED ❑ Distance to nearest: Well rp Foundation - Property Line SEEPAGE PITS 'i Depth as , Size Number SUMPS U Distance to nearest: Well C�a-r: Foundation ,.20r Property Line DISPOSAL PONDS IT 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 performanceofthe 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, i shall employ persons Subject to workman's compensation laws of California." The appli t mu 1 or all required inspections. Complete drawing on.reverse side: ,-� Signed Title: ® K Date: A- ix - i _ PARTMENT USE ONLY Application Accepted by� �,�� Area 42— _ ❑ Stk 466-6781 Additional Comments: _,(� Lodi 369-3621 Pit or Grout Inspection by Date �� ryj ❑ Manteca 823-7104 Final Inspection by "T�D�Q Date �3 ❑ Tracy 835-6385 Applicant - Return all copies to:. Environmentalermit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEiVEO,BV GATE PERMIT NO. INFO I g3-1212 45 - 10/82 500 EH 13-24 REV. 10/82 14-26