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APPLICATION FOR'P ERM1' . lILJJ SAN JOAQUiN LOCAL HEALTH DISTRICT oO1601 E. HAZELI'ON AVE., STOCKTON, CA PERMIT NO. UL� 91J `A t. Telephone (209) 466-6781 ' SAN JOAQUIN LOCAL PERMIT EXPIRES,1 YEAR DATE ISSUED FROM DATE ISSUED " HFALTH ®lSTRV., (Complete in Triplicate)- Application is hereby made to theiSan 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 well/pump and the Rules and Regulations of i7he San Joaquin Local Health District. Job Address .�D��J E L7�K(,ilooD r D ,S�Name hq��/N'Et7VAI Owner's Name 10;aL macr,''61a . Address'._ E Phone 9S/p Contractor's Name 6/6S0AI W,9-4L 7VJ44!JNQjlcense No, " 3'974 _Z, Phone 7i57 3 3 77 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR f OTHER ❑ F r DISTANCE TO NEAREST: SEPTIC TANK ol�O SEWER LINES cit SO DISPOSAL FLO. PROP. LINE a S-' k FOUNDATION AGRICULTURE WELL �_OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ID Industrial N Open Bottom ❑Manteca Dia. of Welt Excavation E 1pg p 45;7 is �-Domestic/.Private 9-Gfavel-Pack ❑Tracy Dia. of Well Casing A�[45 . ❑ Public Other Delta❑ ❑ Type of Lasing I j Irrigation Approx. ❑Eastern Specifications Depth — 0 Cathodic Protection Depth of Grout Seal ❑ Geophysical --)Other of Grout 9 s�¢C,C C itA'B�i/T rj40" ❑Other Surface Seal Installed by •61 :2711:114(_IAI� Repair Work Done Type of Pump 54e�5 H.P. I'State Work Done" /e fJ't[Mf%- Well Destruction'? Well Diameter Sealing Material (top 50') WELL g7eez2rE -?"AA _ r. Q j Depth f Filler Material {Below 509 T TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [7j- (No septic tank or seepage pit permitted if public sewer is 6 available within 200 feet.) Installation will serve: Residence _ Commercial — Othee Number of living units: I Number of bedrooms Lot size Character of soil to a depth o' 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal' I SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ClI ■'9 ( LEACHING LINE ❑ No, C'.Length of lines*- Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS E j Depthl Size Number C SUMPS ❑ Distance to nearest: Well Foundation Property Line - 01SPOSAL PONDS ri---LI T # r ; " ... _ f I hereby certify that I have pr1pired this-application and that the work will be done in accordance with San Joaquin county r( ordinances,.state laws, and rules and regulations of the San iloaquin Local Health District. 4 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannerx as to became subject to workman+;compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons Subject to worklan's compensation laws of California. ' The applicant ust,call fo alllreq r d 'zspections. Complete drawing on -reverse side. Signed X• Y^�. Titley" "—= � �"? _ Date: 7 OR PARTMENT NLY 0 .— wo Application Accepted by Area Std 466-6781 Additional Comments: [J Lodi 369-3621 t Pit or Grout Inspection by Date 0-3v-Q1 ❑ Manteca 823-7104 Final Inspection by ate tf- -1+4-f L7 Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ` INFO �p �b 3Yoc ---r- /g`L -3�~`01 - EH 13-24 REV. 10/82 10/82 500 14-26 1<1$