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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT q✓6 1601 E. HAtELTON .AVE., STOCKTON, CA PERMIT NO. a _ff_ _ 4 Telephone (209) 466-6781 DATE ISSUED �4 PERMIT EXPIRES I YEAR FROM DATE ISSUED 4 (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 welt/pump { and the Rules and Regul ions of the Sa Joaquin local it istrict. Job AddresS division Name Owner's Name Address 0 S$ .44V Phone Contractor's Name A*A&S d License No. 48 Phone li 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 AGRICUL?URE WELL OTHER WELL -PITS/SUMPS r' ` o r... ~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial ' U Open Bottom ❑Manteca Dia. of Well Excavation rl �'�~ '•�, �• LL +❑ g Domestic/Private �Gravel Pack �Tracy Y,, � Dia. of Well Casio '% ( j Other ea •` r ��• +� ,' 17 Public �r ..-._J ❑Del Y Type of Casing 71 Irrigation:] '+,, Approx. ❑Eastern - ' Specifications Cathodic'<Prot`ection Depth ❑ Depth of Grout Seal ❑Geophysieal "�`� Type of Grout q ❑Other., '. Surface Seal Installed,by 'Repair Work Done [J Tlfpe'.-of�Pump K.P• State Work Done 10 . .,, If Well Destruction.❑ Well Diameter Sealing Material (top 50') 1 Depth _ Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW-INSTALLATIONr,REPAIR/ADDITION 0J,:(No-septic tank or seepage pit permitted if public sewer is �� sa 4 - �- -. �.. available within 200 feet,) Installation will serve: Residence Co_mnercial Other r • r. Number of living units: Number of bedrooms iot size E;f.t... 400 Character of soil. to a depth of 3 feet: �� Water table depth _ SEPTIC TANK, +Type/Mfg, �� Capacity ments No. Compart PKG. TREATMENT'PLT ❑,f.;Type/Mfg '' .�^- ```Capacity Method of Disposal +� d Property Line SEWAGE SYSTEM Distance'to nearest: Weli Foundation P Y DESTRUCTION ❑ s, LEACHING LINE No. & Length of lines Z '—' Total length/size + � Property Line' `?': ` FILTER BED j] Distance to nearest: 'Uel — Foundation ) SEEPAGE PITS Depth , Size ' 1' Number• '7--, , . <- Line SUMPS Property LJ Distance to nearest: "Wel'l-'' 'r-- Foundation O� °+'�•� P Y Lin - .- Y DISPOSAL PONDS ❑ - r ? ti t• ;:fi: ` 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 P1.5' issue , i shall not employ any erson in such manner as to•become subject to workmani;compensation laws of California." Contractdr's ing or sub-contractin' - nature certifies the follbwing: "I certify that in the performance of the work far which this {S'e�mlt issued, I shall emplo sons sybject`to workman's compensation laws of California." The appli 3 .1-f all t=iiZ�amplei�f dra n on reverse side. -� Signed Tittle: f Date ' FflR ART NT ONLY? ' !r Application Accepted by a/ USE _ ,e. A ea d C] Stk -466-6781.: +' .`� -A ,Additional Comments: ' Lodi ^'369-3627.�r( lPit or Grout Inspection by Date ❑ Manteca 823-1104 j Date _ -a- ( iracy 835-6385 Final Inspection by I'� Applicant— Return all copies to; �`Envi .H entalealth'Permit/ erv�ces 1601 . Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE 71Mi5UNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 10/82 500 EH 13-24 REV. 10/82 14-26