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APPLICATION fOR PERMIT "r SAN JOAQUIN LOCAL HEALTH DISTRICT r y y-�� 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �_� � Telephone (209) 056-5781 je DATE4ISSUED Y I PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to~the San Joaquin Local Health District for a per..,it 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. 1852 for well pump and :he Rules and Regulations of the San Joaquin`Local Health District, Job Address .pG�✓l1 : 1 l.t�i!/� lEa/�--i ` Subdivision Name Owner's Name C C"/!t/r"�41/.. - ^1 / ' Address ' Phone r^ Contractor's Name ,��9%/c'/_.�">''r�;✓ .�r4, r License No. ?;�"'�✓. .,xi!� � _Phone TYPE OF WELL JPUMP WORK: "'C�- NEW WELL- WELL REPLACEMENT D STRUCTION"i J,"a 4 ~ PUMP INSTALLATION C3 SYSTEM REPAIR OTHER i l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE l FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ ~ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J i�Industrial ED Ope�Bottom [j Manteca Dia. of Well Excavation _ Domestic/Private F-1 Gravel Pack L_�]Tracy Din. of Well Casing Public Other Delta 1� U ❑ Type.-of.'Casing 1_J Irrigation Approx. Eastern Specifications Cathodic Protection Depth i F Depth of Grout Seal (";Geophysical Type of"Grout _ F-jOther Surface'Seal Installed by Repair work Done U Type of Pump H.P. w i State Work Done _ Well Destruction ❑ Well Diameter)- Sealing Material (top 50') Depth ii Filler Material (Below 50') 41 - � r TYPE Of SEPTIC WORK: NEW INSTALLATION iiri' REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is F-1 1 3 4 available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units; A Number of bedrooms _ Lot size 1 >.. 1 (? Character of soil to a depth of i3 feet: Water table depth --------• SEPTIC TANK Type/Mf9L, f?r:_ Capacity 1��O No. Compartments PKG. TREATMENT PLT. Type/Mfg ` I Capacity � ,.M shod of Disposal �. �to±nearest: W f SEWAGE SYSTEM Di'stance _ foundation Property Line r ^ t. DESTRUCTION ❑ _ _ -.._---- LEACHING LINE V No. 6 Length of lines '. % Total length/size FILTER BED ❑ Distance to nearest: WCC�/r foundation ci-+'/ Property Line. /!l — SEEPAGE PITS r_1 Depth Size - Number _ SUMPS Irl Distance to n4rest: Well Foundation Pee perty Line DISPOSAL PONDS [_I 1 I tereby 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 Lgcal^health District. Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this i permit is issued, I shall not employ any person in such manner as to become subject to workman's 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 workman's compensation laws of California." The applicaI ,,must call for all r fired inspections, Complete draw' on reverse side. IDDyyJJ _ Date: �. Signed lt �•,,,ie_. � Title: RTM U Ly Application Accepted byArea 5tk 456-6762 �\ 'N Lodi 369-3521 Additional-Comments: _ �✓ _ _ (- Pit or Grout Inspection by_- Y t Date ct Manteca 823-7104 Final Inspection by Date l-- Ll • U ,'racy 835-6385 Applicant - Return all capias to Environ cal Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 FBASE AMOUNT `DUE AMOUNT REMITTED RECEIVED BY BATE FEE �q^---~PERMIT-ANO. INFO ----"t) —' - �a3'> �lJ� _.. LH 13-24 REV. 10,'92 �j�J� 0 16/82 Soo