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APPLICATION FO1z PERM;T �I SAN JOAQUiN LOCA_ HEkLTH D:STRiCT 1661 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. Z'"X-:.---7 Telephone (209) 466-6781 DATE IS SUED -�A-)3 ii PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) E�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, ' ,:Job Address [)3j Subdivision Name Owner's Name �7AA1r I �,4 f -T Address Zia Phone ,Contractor's Name r=44 V2> License No. yS" ,7� Phone 41 11.TYPE Of WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION*❑ —SYSTEM REPAIR -OTHER ,DISTANCE TO NEAREST: ,SEPTIC TANK i `SEWER LINES ISPOSAL FLD. PROP. LINE ) FOUNDATION i I AGRICULTURE WELL OTHER WELL PITS/SUMPS jj INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f U Domestic/Private ❑ Gravel +Pack ❑ Tracy Dia. of Well Casing I� - ❑ Public ❑ Other R ❑ Delta Type of Casing w. Irrigation Approx. ❑ Eastern ❑ Specifications Cathodic Protection Depth v ` Depth of Grout Seal . • S. ❑Geophysical , Type of Grout _ §J�Otter F Surface Seal Installed by t=. Repair Work Done ❑ Type of Pump H.P. State Work Done CA yWell Destruction ❑ Well Diameter :r. Sealing Material (top 50') _ �J Depth Filler Material (Below 50') ; _ X iiTYPE�OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDDITION :i (No septicCtank,or seepage pit„permitted,if-1public sewer is available within 200 feet,) Ei Installation will serve: Residence _✓ Commercial Other E{ Number of living units: Number of bedrooms Z” irLot sizeX/[� ([� Character of sail to a depth of 3 feet: � �J y —. ---.-� -- .. �� Water table depth ,(SEPTIC TANK Type/Mfg Pgl-L Capacity 12-040 No. Compartments '` — �`PKG. TREATMENT PLT, ❑ Type/Mfg k Capacity Method of Disposal « SEWAGE SYSTEM Distance to nearest: Well A Foundation: /(1 t Property Line �1 /1/ DESTRUCTION +--J i; ,is, $jr C, e !LEACHING LINE tJ ko & Length of lines i ; Notal length/size €1FILTER BED fix' Distance to nearest: Well i Foundation# Property Line ISEEPRGE PITS1Apth Size Number SUMPSd Distance to nearest:Well R Foundation Property Line DISPOSAL PONDS l� ❑ a E I hereby certify that I have prepared this applicationtand 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 workmant compensation laws of California." s Contractor's hiring or sub-contractingsignature certifies the following: "I certify that in the performance of the work for which 11this permit is issued, I shall employ persons subject to workman's compensation laws of California." + The applicant must call for it requir nspections. Complete drawing on reverse side. Signed X " Title: 'l _ Date: 4-1 44.3 OR Q01141MENT USE ONLY Ej Application Accepted bylft�lArea eJ ❑ Stk 466-6781 i Additional Comments: ❑ Lodi 369-3621 ` Ei Pit or Grout Inspect' y Date ❑ Manteca 823-7104 ! Final Inspection by �%.=`71t° Date ❑ Tracy 835-6385 �+ Applicant - Return all co a to: Ervironmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i f INFO TTED REGEItlED'BY 'DATE PERMIT N0. Lt� FEE BASE AMDUNT DUE AMOUNT")t�EMI € EH 13-24 REV. 10/82 10/82 500 G ;+ 14-26 , i