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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. d Oyu/ Telephone (.209) 456-6781 DATE ISSUED O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, T � c ion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules 4i�R i a ions of the San ]oaauin Local Health District. Job Address �Ja.,re �y R4 Subdivision Name _ )n©;^p Owner's Name Ross }ma y-u►a�✓�CE'_ :k Address O W vAA gA J_1.4&eo CO3 Phone �S'�] 12-S Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL p WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^0 I Industrial Lf Open Bottom Manteca Dia, of Well Excavation G I U Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public �j Other ❑ Delta Type of Casing Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal 1-1 Geophysical t„ Type of Grout D Other Surface Seal Installed by l Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U well Diameter Sealing Material (top 50') �. Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALIL�J�QN REPAIR/,ADDITION U (No septic,tank or seepage pit permitted if public sewer is v available within 200 feet.) + Installation will serve: lR,esidence Commercial _ Other ,A Number of living units: ,1, Number of bedrooms _ Lot size �:5 rTc1'tr S Character of soil to a depth of 3 feet: iCt.AAr qoCkki - tJo Meo r-ki Water table depth 'y 2$0 SEPTIC TANK Qj Type/Mfg Ce"Qn - Capacity 4ap� ckg,_1-No. Compartments _ PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c Distance to nearest: Well 7410 1 Foundation /0 Property Line /00 DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance 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. 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 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applic+an must call f al required reequired inspections. Complete drAawi_ng on reverse side, 1 Signed XJ -�✓�L�kll�J, l7g - - Title: ti(AJ['Q_' � +"' Date: v. 1�. EPiRTMEONLY Replication Accepted Area Stk 466-6781 Additional Comments:(—,-/ [ Lodi 364-3621 Pit or GroutInspection by Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copi o: 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 -93" LrJ�v EH 13-24 REV. 10/82 �7 10/82 500 14-.261