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• 1 APPLICATION FOR.PERMIT SAN ,iOA¢UiN LOCAL HEALTH DISTRICT 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 ,oaquin Local Health District for a permit to construct and/or install the work herein ` ance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump described. This application is made in compli and the Rules and Regulationj of the S n Joa uin Local Health District. , Job Address Subdivision Name T Address. ec .Q Phone,W 3 nz/ Owner's Name 8lJ�f ��"� q _5 JOS � � License No. Phony Contractor's Nam zii7 v TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ •.� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL , OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Oia. of Well Excavation 71 industrial ❑Open Bottom 71,Manteca ❑ Domestic/Private C Gravel Pack []Tracy Gia. of Well Casing ❑ Public (J Other Delta Type of Casing Li Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other— """ '� Surface Seal Installed by ! State Work-Dome Repair Work Done I Type of Pump H.P. well Destruction ❑ Well Diameter) ' — I Sealing Material (top 501 -J — Depth , Filler Material (Below 50') TYPE OF SEPTIC WORK: ''NEW INSTALLATIONj_!'�-RFPAIR/ADDITION J (No a tic tank or seepage pit permitted if public sewer is f/ available within 200 feet.) installation will serve: Residence' _Commercial _ Other .•rte Number of living units: Numbio of edrooms Lot Water table depth Character of soil to a'depth of 3 Deet; ." �- " Mf SEPTIC TANK 2----Ty ' Capacity": ' r .—�No ~Compartments Method of Disposal PKG. TREATMENT PLT. (] Type/Mfg.• 1'-* rpa�itY _ SEWAGE SYSTEM. Distance to fnearestWell es Foundation P rDperty Line _ DESTRUCTION'. +-LEA6`UNG-t-I•NE-i '!-- in"—No`"3-Length of l ivies Total length/size FILTER BED ' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS L Depth s Size �� r Number; r i Line S SUMPS jJ Distance to nearest: Well /SD Foundation /D -Property �---- y DISPOSAL PONDS ` amt I hereby certify that Shave prepared this application and that the work will be done in accordance with San Joaquin county Local Health ordinances, state laws, and rules and regulations of the San Joaquin Dist'r_ict. - Home owner or'Ticersed'agen'tRs signage certifies fne foTTowln-g cerf3fy tfiat"in the performance of the work for which this 'r permit is issued, 1 shall not employ any person in such manner as to become subject to Workman§compensation laws of Californiaic Contractor's hiring or sub-contra'Cting-signature'certif tes-the-foj=Iowing.T— certify that in the performance of the work for which y persons subject to workman's compensation laws of4-Califo this permit is issued, i shall emplornia." The applican ust ca f all required inspections. complete�drravringlgp revers e.side� Oatee�/T ems' Signed X - ';,"�•: Ti.the:, v rl .►. OR DEPARTMENT USEONLY $ Stk 466-6781 Appli ion Accepted by—'Z:: .•� f Area-•- - ❑ • Lodi 369-3621 �}1dd_itional Cments: _om ,e• L_.l Manteca X23=J70�41T" .. Pit or Grout Inspection, by ,�` Final Inspection by Date / XV0',-P.b. Tracy835-6385 Applicant - Return all copies to: Environmental He th Permit/Services 16O1�E. Haze9toBox 2009, Stk., CA 95201 `J DATE PERMIT NO. .. SEE__-.BASE ,AMOUNT_DUE__— a�.AMOUNT•REM iTTED, RECEIVED BY_ __�7wQ.,•.,. ....--meq•••-_•• 11 10/82 500 EH 13-24 REV. 10/82 14-26