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APPLICATION FOR PERXa!T SAN JOAQLi" LOCAL.HF4.LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES YEAR FROM DATE ISSUED # (Complete in Triplicate) Application is hereby made'to the San Joaquin Local Health District for a permit to construct'ard/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 H a�ltlh�`!gistrict. , Job Address J Al ` "91-40 CST " suooivision Name ' Owner's Name AL,9AL; �Ti W/1 Address Phone 4�2-��(oce3 Contractor's Name 4S License No. Phone TYPE Of WELL/PUMP WORK: NEW WELL ' �] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑; . DISPOSAL FLD. PROP. LINE �= : " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �'. K�,y,;�•* ly FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` d� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �' y f Industrial 3 ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack FJ-Tracy Dia. of Well Casing " . Public Other Delta ❑ ❑ ❑. s Type of Casing Irrigation 'i. Approx. ❑ Eastern Specifications Cathodic Protection Depth , ❑ Depth of Grout Seal ❑ Geophysical Type of Grout r: ❑Other `¢"'" - ",r Surface Seal Installed by Repair Work Done ❑ Type of Pump r,-H.P." State,14ork Done Well Destruction ❑ .Well Dianeter. . Sealing Material (top 50') = -4 Depths Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION (No septic tank or seepage;pit permitted if public sewer is available within 200 feet.) 67 Installation will serve: Residence Commercial Other' r Q Number of living unitscf Number of bedrooms _ Lot size -/d rQ k 3 feet: Water table depth Character of soil to a depth of G�i��9/5'f ��p SEPTIC TANK ❑ Type/Mfg '' Capacity__ No. Compartments ° ' PKG. TREATMENT PLT. ❑ Type/Mfg ` Capacity'•�f Method of Disposal SEWAGE SYSTEM Distance to nearest: Well foundation $, Property Line DESTRUCTION i-L LEACHING LINE No. & Length of line ^� �� Total length size s 4. �d fILTER.BED ❑ .Distance to nearest: Well Foundation �J r - Property Line / Number SEEPAGE PITS "Depth size SUMPS D Distance to nearest: Well Foundation 'Property Line f DISPOSAL PONDS ❑� 't �--�,. -^ '..- "" �_ .''...,`....'. - I hereby certify that I have prepared this application and that the workwi11Lbe done in accordance with San Joaquin county ordinances, state laws, and rules-and regulations of the San Joaquin Loc.ah Health District., Home owner or licensed agent's signature certifies the following:. ".I certify fhat�in the performance of the work for which this PL is issue , ;I shall -not employ any person in such-manner as:to become subject to workmanS compensation laws of California." Contractor's Ing or sub-contracting s' natur,' , ertifies the fol'owing: "I certify that in the performance of the work for which this permit ssued, i s lltiemploy er ons ' ject.`to workman's Foil ensation laws of California." The applic t 11 all re a ions. ICamplete�i ®g reverse side. c% itle: Date:,JL Signed X MENT USE ONLY' Area �\ i y"' - A Application Accepted by - - Additional Comments: I -�W [ Lodi 369-3621 Pi -or Grout Inspection by Date q' Z`1- gj ❑ Manteca 823-7104 rr Tracy 835-6385 Final Inspection bye Date^�}i - - '3 Applicant - Return all copies to: vironmertal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i p + FL-INF BASE AMOUNT 4DUE AMGUNT REMITTED RECEIVED BY OATE PERMIT N0. _ ' w X10/82_500- . EH 13-24 REV. 10/82 l 14-26 i �•