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s s r APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT �fr/6 3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) AVIV , . d q 5— �q 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 ��oZ $�a �. /�/�'�aio 9%8ozy Subdivision Name Owner's Name G�. �_,9?�'0� Address Syme-..095 JoG Phone Contractor's Name AF /9A5L4eAf.V 4 SOnr License No. Y5/y- 89/ Phone S-2-7- 97, ! TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR j OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom ❑Manteca Dia, of Well Excavation C Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical -� Type of Grout Other Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Q } Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') V �� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION EJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: J Number of bedrooms 3 Lot size 49vcz — Character of soil to a depth of 3 feet; - el Water table depth �1d SEPTIC TANK Type/Mfg ,yp C s T Co C. Capacity /400 No. Compartments 9- PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well A OO Foundation 5�5' Property Line /450" SEEPAGE PITS ❑ Depth Size Number SUMPS Ej Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I 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 workmant 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 laws of California." The applicant mu cal for a 1 required inspections. Complete drawing on reverse side, 9YSigned X" Title: Date: — F RTM USE ONLY / Application Accepted by pyz -- Area Q0 ❑ Stk 466-6781 —11 6Z Additional Comments: l ❑ Lodi 369-3621 Uw,- .e, 4j,/ Pit or Grout Inspection Date EXManteca 823-7104 .(V rk 71 t Final Inspection by Date 2-3 ❑ Tracy 835-6385 dr,,.q. keV- f rrt Applicant - Return all copi a: nvironmental Health Permit/Services 1601 E. Hazel on Ave., P.D. Box 2009, Stk., CA 95201 G 6,14 ro.(.rt FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO CIU�r rLwvL EH 13-24 REV. 10/82 10/82 500 14-26