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4_4 L.,yl' � M �... • APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE.,;STOCKTON, CA PERMIT N0, 02 57 z- 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, T p ion is.gade in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for.well/pump ' and the Rulei�R 11 ns��j)Pe San Joauin Local Health District. , Job Address - V/W ABS' Subdivision Name Owner's Nam e �/► s Address ione r Contractor's Nam _ License No. "� _ _ _ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT (] DESTRUCTION f + PUMP INSTALLATION SY•STEM,REPAIR, OTHER-e— -m- - r DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FCD. PROP,...L.INE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iJ Industrial/ U Open Bottom Manteca Dia. of Well Excavation L}Domestic%Private Gravel Pack [-]Tracy Dia. of Well Casing r. Public Other ❑Deita Type of Casing Li irrigation __ i•Approx. �Eastern Specifications _ 1 Q Cathodic Protection I-� .[�;Depth Depth of Grout Seal, ' +(�Gsophysicai Type of Grout +` they Y Ya ,�,;,� Iv.,' Surface Seal Installed by Z Repair Work Done G' Type of Pump H.P. State Work Done I �y �I .._ Well Destruction 3. Well*Dirmeter Sealfng�'Matej aN,(top 501) Depth ` 1 Filler Material,(Below 50') h TYPE•OF..SEPTIC WORK: NEW INSTALLATIOI j REPAIR/ADDITION U (No:�septic tank or seepage pit permitted if public sewer is a ! - I ' available within 200 feet.) 1 Installation will serve:I !Residences.: Commercial .1 Other t � � / yI.' Number of living units: -Z, 1 Number of b draoms ►� Lot size in Character of soli to a:depth of 3 feet: � A Water table depth SEPTIC TANKType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity _ Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line. i DESTRUCTION ❑ ! LEACHING LINE U No. d?Length of lines -' Total jlength/size t r / FILTER BED Distance to nearest: Well dfit Foundation _I�_ Property-Line SEEPAGE PITS [) Deptfl Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i1' I hereby certify that I have p"pared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rulds and regulations of the San ,;oaquin Local Health District. Home owner or licensed agent'sfignature c'erti.Ti€s'the following: "I certify that in the performance of the work for which this permit is issued,zi•shall not employ any personlin such manner as to become subject to workman§compensation laws of California." -"'-Co-ntractor s"tTirfng,',o'r sub-con.trac. ind signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall a '1(oylpersonsNsUbject to workman's compensation taws of California." The applica t must call for al jr uire inspections. Complete drawing on reverse side. r Signed Title: 2AlAGe-- Date: clj- DEPARTjfENT USE ONLY � i Application'Ac7cept6d' ----Area -_jg:s 7^tea--:«.-...,-�,.Stk�..._466-67.81.. Additional Comments: - Lodi 369-3621 r Pit or Grout Inspection by 10, Date oaf Manteca 823-7104 I Final Inspection by Date -J�—�- Tracy 835-6385 Applicant - Return all copies to: EnvironrYhUl Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 i FEE L BASEMOUNTI DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, -INFO -82 14-26 s,.