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Asa r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 93 _S�� 11 -1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ;Telephone (209) 466-6781 DATE ISSUED PERMIT;-EXPIRES 1_YEAR FROM DATE ISSUED !- (Compl:ete;in Triplicate) a Application is hereby made to the-San Joaquin Local Heaklth 'Di'strict for a permit to construct and/or install the work herein described. This application is made in compliance with.sen..Joat}uin County Ordinance No. 549 for sewage or No. 1862 for well/pump id the Rules and.Regulations ofthe San Joaquin Local Health .District. Job Address. /� J Zo a 4bdiv�ionme Owner's Name UY4AO Address ,, te.c')Q�+ Phone Z Contractor's Name e{e License No.. Q Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION q PUMP INSTALLATION [] SYSTEM REPAIR [7 OTHER ❑ I OR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial [}Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public []Other Delta Type of Casing € irrigation Approx.' Eastern Specifications ; Y ❑ Cathodic Protection Depth � ,Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface'.Seal Installed by A Repair Work Done ❑ Type of Pump t H.P. State Woi�k Done Well Destruction ❑ Well Diameter,[ Sealing Material (top 50') - Depth 1 Filler Material (Below 50') v��+ TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ (No septic tank or seepage p}t prmittd if avaeilableewithinu200cfeet.) is Installation will serve: Residence ✓ Commercial _ Other Number of living units: _L_ Number of bedrooms 3 Lot size ��AeA Character of soil to a epth of.3 feet: A-Ak Water table depth � ! SEPTIC TANK. Type/Mfg' capacity f 5�,_ No. Compartments �- Capacity Method of Disposal ? PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM �' DistanceIto nearest: Well _ Foundation erty Line Prop DESTRUCTION t. j } LEACHING LINE No. A Length of lines .3 f r Total length/size �; t Property Line i S FILTER BED Distance..to nearest: well 1 OD'- Foundation s y �--,— 3 „Size tr Number SEEPAGE PITS Depth Propert t SUMPS- ❑! Distance to nearest'`' Wel l 1 DLFoundation _ — y Line f DISPOSAL PONDS ❑ I� j I hereby certify that /.have prepared this appI` ation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules-and regulations-of the SanvJoaquin 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 workmathrI& compensation laws of Californiaic I Contractor's hiring or sub-contracting signature certifies-the following: "I certify that in the performance of the work for which I this permit is 'ssued, I shall em loy per ons subject to workman's compensation laws of California.” The appl' ant mus call or all a re inspections. Complete drawing on reverse`side': pate: +�Signed Title: FOR DEPARTMENT USE ONLY ', Stk 466-6781 r17 I Application Accepted by Area _ __ Additional Comments: - ALodi 369-362117 Manteca 823-7104 Pit or Grout Inspection by Date. Date L' 3 ❑ Tracy 835-6385 Final Inspection by o: Environmental �lealth Permit/Services 1601 E. H e lton Ave., P,O. Box 2009, Stk., CA 95201 Applicant - Return all copies t• FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY SATE PERMIT NO. INFO A q oa V- 6 1S 3 $3 -5 5 ,,, _ T • ._v 10/82 500 EH 13-24 REV. 10/82 14-26 �. �: