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APPLICATION fOR PERMIT . SAN JOAQUIN LOCAL'HEALTH DISTRICT 43=13 7 7 1601 E: HAZELTON AVE., STOCKTON. CA PERMIT N0. Z Telephone (209)466-6781 DATE4•ISSUED 12-01q�✓ i' If PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (complete in Triplicate) . Application is hereby made to the San Joaquin Local Health Distto construct and/or insta rict ll the work herein described. This application is made in compliance with San Joaquin fora permit in County Ordinance No. 549 for sewage or No. '1862 for well/pump and the Rules and Regulations of the San Joaquin,Local Health District. Job Address 001.4 yy tMlx� 0e in'`t"*( `• Subdivision Name, Phone Owner's Name / r'a/r,4113?. M11I /j�� Address License No. :L S''ii�.�y.� Phone �'�.�Q - Contractor's Name �Al��1.f1� 'Sd.�/.� - •- _ DESTRUCTION TYPE OF WELL/PUMP WORK: T.,.,NNEW.WELLt :•:� ],1 WELL REPLACEMENT` Q; t '+� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 _ DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER AL F O. PITS/SUMPS FOUNDATION AGRICULTURE WELL _ vJ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^� ' Bottom Manteca Dia. of Well Excavation �1 ❑Industria] ❑Opens ❑ ❑Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing I ❑Public ❑Other ❑Delta,•- �PT,ype-ofaCasing ❑ Irrigation Approx. ❑Eastern Specifications - Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type ofGrout ❑Other SurfaceISeal Installed by -- L Repair Work Done Type of Pump H.P. State Work Done �_ _ x Well Destruction ❑ Well Diameter Sealing Material (top 50') W Depth i Filler Material (Below,50') pr' er TYPE OF SEPTIC WORK: NEW INSTALLATION i�et' REPAIR/AODI'ION E] (No septic tank or seepage pjavae ableewithid if nu200cfeet �s .) Installation will serve: Residence ! Commercial Other -" Number of living units: .1 Number of bedrooms Lot size . A C.2 e.S { 4 Water table depth f�0 Character of soil to a depth of13 feet: tom_. Capacity No, Compartments .Z /?.off��yt. � Q SEPTIC TANK FX Type/Mfg A, e I Capacity - Me`thod of Disposal PKG. TREATMENT PLT. ❑ Type/Mfga Property Line SEWAGE SYSTEM Distance-to,nearest: Wei- _ foundation !1) C DESTRUCTION C] r _ LEACHING LINE [—jNo. & Length of lines / Total length/size 7t1 FILTER BED F-1Distance to nearest- Weft, Foundation Sp! Property Line ' Size SEEPAGE PITS ❑ Depth Property Line i SUMPS ❑ Distance to nearest: Well foundation /F p 4 DISPOSAL PONDS ❑ b 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 Lqcal-Health District. Home owner or licensed agent's signature certif suchfmannernas to becomeysubjectthat ntohworekman t compensatrformance of i�onwlaws fof California." 1 permit is issued, I shall not employ y P Contractor's hiring or sub-contracting signature certifies the following: I certify that in the performance of the work for whit this permit is issued, I shall employ persons subject to workman's compensation laws of California." The app lica must call for all r ired inspections- Complete draw' on reverse side. Date: 2 Title: /f l Signed X OR RTM U HLY Area 007 ❑ Stk 466-6781 Application Accepted by. Cl Lodi 359-3621 Additional•Comments: - ❑ Manteca 823-7104 Pit or Grout Inspection by dL Date Date �� Tracy 835-6385 Final Inspection by P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to:. Environ al Health Permit/Services 1601 E. Hazelton Ave., MIT FEE BASE AMOUNT 'DUE AMOUNT REMITTED RECEIVED 8Y DATE Q q��RI �� INFO o �crZ'�-"l (J f} "V 10J82 500 EH 13-24 REV. 10J82 _ . 07