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Y APPLICATION FOR PERMiT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456.6 781 I j - DATE ISSUED 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. This application is ma}de in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump W and the Rules and Regulat&ns L moi) Sap„Joaquin Local health District. Job Address M�I�Fri�jr4: A 2�. Subdivision Name Owner's Name Address S� ro MAP— aSA R+D Phone Contractor's Name FLDYD E- woob License No. "F?�•7Z. — Phone r-- TYPE OF WELL/PUMP WORK: Q"NEW:W ELL. E] WELL REPLACEMENT [] DESTRUCTION ❑ y y " PUMP• INSTALLATIONy ElSYSTEM REPAIR LJOTHER DISTANCE TO NEAREST: SEPTIC ', 1,.4j 4 SEWER LINES DISPOSAL FLO.£ i—PROP-�-LI•N&�a.,a�-. FOUNDATION AGRICULTURE WELL OTHER WELL i PITS/SUMPS,' INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial U Open Bottom .?;❑Manteca — "Dia."'of"Well Excavation l { Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Liell Casing ❑ Public ❑OtherDlt Delta y ❑ ) Type of Casing V Irrigation Approx. j v❑Eastern Specifications ❑ Cathodic Protection Depth ' • Depth of;Grout Seal z ❑Geophysical s Type of Grout p Other a Surface Seal Installed by rt ti Repair Work Done [-] Type of Pump H.P. %State Work Done Well Destruction 1❑ Well fDIIameter # Sealing Material (top 50") Depth r^ Filler"Material (Below 50'} m TYPE OF SEPTIC WORK: NEW,4NSTALL•ATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Ah , available within 200 feet.) Installation will serve: (Residences ~f! Commercial Other 3 Number of living units: Number of bedrooms Lot size 'Y 1 6^ - Water table depth Character of soil to a depth of 3 feet: f'. SEPTIC TANK Type/Mfg "5Jy Capacity Z� No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well i V_ Foundation.._;__ 0 Property Line _ 111-1 DESTRUCTION 1 t LEACHING LINE No. &Length of lines Total length/size Q )C 7L i Property Line FILTER BED ❑. Distance to nearest: Well _ Foundation P Y k SEEPAGE PITS ✓� Dt Z� Size �� Number SUMPS ❑ Di_stance to nearest: Well I Foundation S& Property Line �S DISPOSAL PONDS ❑ YFt �YC4ST!/t7Cr �QT �f ;..a2C—,C.o&.h 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, 1 shall not employ any person in Bach manner as to become subject to workman$ cnmpensatian 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 laws of California."zj or The applicant must call for( 11' required inspections. Complete drawing/on reverse side. Signed X Title: r Date: R DEPR MENT USE ONLY 4 Area � ❑ Stk 46fi-6781 Application Accepted� by ❑ Lodi 369-3621 Additional Comments: t F Pit or Grout Inspection}by Date Manteca $23-7104 I I n Date 3—�� ❑ Tracy. 835-6385 Fina.lInspection by Applicant - Return all copies to: ,_ Ervironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CR 9 5201 .1�- § II FEE BASE'i 'm AMOUN; DUE �AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. F INFO � -•�= t"' � ti L,.A c. - 10/82 500 EH 13-24 REV. 10/827` .,.. /��j { GdL �� f 6/ 14-26 �; a€ 14 ,. l