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}I s APPLICATION FOR P€;'MTT R s UU S91.Pa JOAQU;I,' LOCAL HEALTH u:STRIvT }} // e 1601 E. HAZELTON AVE- STOCKTON, CA PERMIT NO. f3 r i3(PsTeleph1 ne , PERMIT EXPIRES oI YEAR aFROM 6DATEIISSUED , 3 DATE ISSUED � Q-- SANSA i", uil'd LOCAL (Complete in Triplicate) gg � 3 DISTRIC'�t r Applications 4et�b�'made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is madelin 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 LocA Health District. Job Address boa division Name Owner's Name Addre s bX Phone z�-Q q—a`1�Q 1 Contractor's ame :l License No. Phone TYPE OF WELL;'PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ❑� ig PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F,-LD. PROP. LINE } FOUNDATION f AGRICULTURE WELL OTHEP. WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V— !❑ Industrial) U Open Bottom ❑ Manteca Dia. of Well Excavation e LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of well Casing r ❑ Public �': ❑Other L � Delta Type of Casing 71 Irrigation" Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications i 5 Depth of Grout Seal ❑ Geophysical #i Type of Grout ;❑Other "- —Surface,Seal.Installed.by ! Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ WelI Diameter Sealing Material (top 50') (i Depth .G Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑� REPAIR/ADDITION (No septic tank oroseepage-pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence. * Commercial_ Other F •„,�,. Number of living units: �_ Number of bedrooms Lot size Character of soil to a depth of 3 feet: _ „� .�� Water table.de`pth a$--,Z SEPTIC TANK ;. Type/Mfg Capacityr No. Compartments r � PKG. TREATMENT PLT. ❑ Type/Mfg 4, -._Capacity Method of Disposal SEWAGE SYSTEM Distance,rto,nearest:r Well.}-... --A:46 n,, Property Line 1 DESTRUCTION 1 4 i 1�1, °Pr " a . '� Total length/size O � J LEACHING LINE No. & Length of 1 m es ,", FILTER BED Distance to nearest: Well Foundation _ Property Line SEEPAGE PITSa ❑_ Depth - -• Size NumbeF" T SUMPS ❑ Desistance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 Local Health District, Homeowner 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 manner as to become 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 Iis issued, I shall employ persons subject to workman's compensation laws of California." The applicint must call forall equ' ed inspections. Complete drawing on reverse side. Signed xt�V Gtt / __ Title: Date: r2— l [J FOR DEPARTMENT USE ONLY I Application Accepted by Area_- --- ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 I Pit or Grout Inspection bI Date ... n, Manteca 82377104 Final Inspection by Daten��1�- jG� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmen Health Permit/Services 1601 E. Hazelton Ave.,, P.O. Box 2009, Stk., CA 95201 • rINFO E BASE AMOUNT DUE AMOUNT. REM ITT ED RECEIVED BY DATE' q PERMIT NO. O 3~ [3 b O +f EH 13-24 i'REV. 10/82 r # / 10/82 500 14-26 1^