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Ii APPLICATION FOR PERMIT ' SAN .OAQUiN LOCAL HEALTH DISTRICT T 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. i Telephone (209) 456-6781 p DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete.in Triplicate) l:Application is hereby made to the San 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 the San Joaquin Local Health District. !IJob AddressE — Subdivision Name Owner's Name /L.ERE&7'A Vf -�L�t�� ddress — S>r.G✓ Phone d,1]�Ffi/�F ::Contractor's Name 05, MIdopLicense No. $r r, Rhone t §TYPE OF WELL/PUMP WORK: NEW WELL r] WELL REPLACEMENT D DESTRUCTION I PUMP INSTALLATION SYSTEM REPAIR 0 OTHER U P I DISTANCE TO NEAREST: SEPTIC TANK } SEWER LINES .DISPOSAL FLO. PROP. LINE i5 FOUNDATION I AGRICULTURE WELL. 1 "�. %.OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA, y CONSTRUCTION SPECIFICATIONS 'I J Industrial U Open Botiom Q Manteca I Dia. of�WellExcavation I U Domestic/Private [] Gravel Pack ❑ Tracy Dia. oflWell Casing l f 1 Public F-1 0ther , ❑ Delta '" 3 r Type cf Casing . Irrigation Approx. Q Eastern Specifications Cathodic Protection Dept p "Depth of Grout Seal Geophysical Type of!Grout I, LJ other x" 4 x Surface Seal Installed by f I B Repair Work Done [J Type of Pump "S. N.P.• . State Work Done 1► Weil Destruction ❑ Well Diameter A Sealing Material (top 50') E Depth cFil 1 er,Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITIONU (No septic tank or seepage pit permitted if public sewer is s available within 200 feet.) V Installation will serve: Residence v' Commerciale-4 Other' Number of living units: Number of bedrooms, _ Lot size' !1< q Character of soil to a depth of 3 feet: e A Water table depth { SEPTIC TANK Ek" Type/Mfg !�arle�rFy: '._PSL __ CapacityFQNo. Compartments 11 PKG. TREATMENT PLT. Type/Mfg F Capacity Method of Disposal Foundation l Property Line -10 SEWAGE SYSTEM Distance to nearest: Well /� /f! DESTRUCTION G �' !I LEACHING LINE F�< No. & Length of�Iines �'O z Total length/size /dg O FILTER BED Distance to nearest: Wel lIN/��„Foundation ].d Property Line ,� Wj W SEEPAGE PITS Depth + �� Size '.-'Number SEEPAGE / Line Property j SUMPS �� Distance to nearest: Well .. Foundation F P Y !t DISPOSAL PONDS ❑ _ EI 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Ei 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 thatlin 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 is issued, I shall employ persons subject to workman's compensation 1 ws of California." The applicant must call for all required ' ections""Complete drawing'on reverse side. 3��G —3 1 Signed X Title: ® Date: 9 �7 ,,I 7� . j R TM ENT USE ONLY Stk 466-6781 �t V-1 Application Accepted by Area / 0 Lodi 369-3621 Additional Comments: �l�, Manteca 823-7104 Pit or Grout Inspection by /024 Date 16-31457— LJ it Date 'h(9- X\ Tracy 835-6385 Final Inspection by Stk., + Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 952D1 i + 'I I I; FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT . NINFO 3-03 S ' I0/e2 soo EH 13-24 REV. 10/82 S �+ 14-26 i Il