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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 40. Telephone (209) 466-5781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is rade in compliance with San Joaquin County Ordinance No. 539 for sewage or No. 1862 for well/pump and the RuleS)A))n�Jgglations of the San Joaquin Local health District. Job Address .,+C" � S. MMICZ 1 a0AOubdivision Name Owner's Name C`NAR�tS QjRV*AP y+11 Andress 'hone Contractor's Name 71er G lZt License No. 3`?/ °hone TYPE OF WELL/PUMP WORK: NEW WELL � WELL REPiRCEMENT � DESTRUCTION _j PMP INSTALLATION SYSTEM REPAIR ("� OTHER U DISTANCE TD_NEAREST: SEPTIC TANK _. SEWER LIMES DISPOSAL FCD, _ PROP. LINE FOUNDAT10N AGRICULTURE WELL _. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CL'NStRjUC 10'4 SPECIFICATIONS Industrial Open Bottom u Manteca Di ell Excavation ✓i 4 yi Domestic/Private Gravel Pack v Tracy Dia. oflWell Casing , Public CjOther Delta Type of Casing LW 1 r rrigation �..._ _Approx. Eastern Specifications + J^y Cathodic Protection Depth _...._. -..s Depth of Grout Seal 1-1 Geophysical Type of Grout _ f;Jtrier Surface Seal Installed by Repair Bork Done Type e of Pump N.P. State Work Done 1 _.. _ ._� well} Destruction [j Well Diameter Sealing Material (top 501) t . ih 'I —.r Depth _ filler Material (Below 50') r} 'TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Tg (No septic tank or seepage pit permitted `f public set.' ) 7s available within 200 feet.') installation will serve: Residence Coati rcial Other # . Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet:�_CScvw 'outer table depth 3 No. Com artn�ents i i SEPTIC TANK l TypeJi fg i Capacity. _ P _ Pa TREATMENT PLT. l Type/Mfg # Capacity W. � � Method of Disposal E # SEWAGE SYSTEM ce,to,nearestt:. 4e11._ Foundation property Line _� . y✓ I DESTRUCT'.ON LEACHING LINE I No. & Length of lines i`•' � ' Total length/size s ♦ , F1LlER BED j i Distance to nearest: Well �� foundation ' p_ Property Line T? ; SEEPAGE PITS ] Depth Size _.... _._ `•Number I SUMPS !. Distance to nearest;_tiell_ _ ..". .Erjucdaxa�n Property Line 34OSAL PONDS I Hereby cei4.tify that I have prepafed this application. and that he work-' be done in accordan with San Joaquin county ord.inances,jstate laws^'and'.rules`and regulations of the San Joaquin Local health District. Hone owner br licensed agent's signature certifies the follpwing:."I certlfY Frsa rr:the per orc'ance of the' k or which this permit is issued. I shall not employ any person in such rwVner as to become subject to workr,,an�s`compensation laws o. CaIifornia. Contractor's hiring or sub-contracting.s-igna�>?cer ifies the following: "i certify that in the performance of the work for which this peraritiis issued,�I.sha•ll employ persons subject'rto workman's compensation laws of-*Cal4fornia."� t. The.app`I.icari�yy�;,t call for all requi ed inspections. "Complete drawing on reverse side, 1� _ - Signed'X_ &V.-; Title: �� Z`__ _ `A _ Date: GRE RRTMEN�•.USE ONLY; Y Application Accepted by + AreaStk 456=5791' Additional Comments: _ # ( t.od 359-3821 + t , ,�`+!anteca 823-71,34. Pit or Grant inspection by _ �.. pate incl—hs'pecrinn—by _ _ a Date U 'racy 835-6385 -- Applicant - Return all copies to: Environmental,health Permit/Services 1'6ol F. Nazel.on Ave_ P,O. Box 2009, Stk.,�LA ,9$201 FE `+ AMOUNT DUE j� AMOUNT REMITTED # RECEIVED BY DATE PERMIT NO, + NE BASE �� INFO EH 13-24 REV. 10/82 -"A `✓, y.:, f, � r' :0,82 5,3 14-26