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r.. APPLICATION F0 PERN.iT .`'-'.N JOAQL._!: LOCA_ iLTH .:.5 RIOT ? _Q 1601 E. HA_HLTO'I AVE., S?OCKTON, CA PERMIT N0, 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 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 3.252 /ol7J�T,5�Z4U/,✓ Subdivision Name ef4e, okee NodSrnr<o /�•�J�P k- bm Owner's Name �4��, 4j'-p R Address e— Phone Contractor's Name �4FLR l e<f License No. 2 3 Y 3 y 3 Phone 6666—W0 7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION LJ PUMP INSTALLATION (� SYSTEM REPAIROTHER i I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPStoo } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom []Manteca Dia. of Well Excavation lJ Domestic/Private r_1 Gravel Pack ❑Tracy Dia. of Well Casing h' ❑Public C1 Other ❑Delta Type of Casing LJ Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 11m ❑Geophysical Type of Grout [J Other Surface Seal Installed by Repair Work Done �] Type of Pump H.P. State Work Done r. Well Destruction U Well Diameter Sealing Material (top 501) _ � } Depth Filler Material (Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is %= available within 200 feet.) Installation will serve: Residence _ Commercial X Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: e^—I n)eWater table depth bw n SEPTIC TANK Ll Type/Mfg Cp�� /�A�LQ/S/f Capacity 2Yeo No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal rC� SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth 2S< Size y8 Number 7 Q SUMPS Distance to nearest: Well —" Foundation Property Line DISPOSAL PONDS D � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county C 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 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 applicant must call for all requi d inspections. Complete drawing on reverse side. Signed X Title: 7�/i,,.�Fa—L� Date: �—,29-9-3 ` OR DEPARTMENT USE ON DP P Y � C�Y.{fzAA rea Stk 466-6781 Application Accepted b Additional Comments: -«— v€ r�% .A (� Lodi 369-3621 Pit or Grout Inspect' n by /c: �G Date �`� �� Manteca 823-7104 Final Inspection byQAr�p— � � Date ❑ Tracy 835-6385 Applicant - Return all cop 1'No: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO O i T/r!Aj f /'kje r/!• z.x e_, z.+/ crt< .ori .ry�.10/82 500 EH 13-24 REV. 10/82 14-26 �sr E3 1. ftw T