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/i APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, 41-40Y Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) co Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein (1.1 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 he San Joaquin Local Health District. Job Address Subdivision Name Owner's Name /f� V,�bs�jtJn ni¢i!/�C Address �j /�a, ��/ J` �'"` /Z �! /r�! �,.PGn,Gnn C' /� Phone 311-3 Contractor's Name . License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR U OTHER F_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public F-1 Other Delta Type of Casing V Irrigation Approx. EJ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done F—J Type of Pump H.P. State Work Done Q Well Destruction LJ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) installation will serve: Residence _ Commercial _ Other Vd&&Zdqv Aroo7e El Number of living units: _L Number of bedrooms —._L_...__� Lot size 75 XIO0 Character of soil to a depth of 3 feet: 9AA.1,Dy _ Water table depth ` O r SEPTIC TANK ® Type/Mfg p¢ Capacity 12©O No. Compartments 2_ PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well S— Foundation / o __ Property Line DESTRUCTION ® T LEACHING LINE U No. & Length of lines Total length/size c FILTER BED Distance to nearest: Well _5V r Foundation r Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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 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 laws of California." The applicantcall for all required inspections. Complete drawing on reverse side. Signed X Title: �47:,CDate: - FOR D PARTMENT USE ONLY Application Accepted by _10Area t Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 7_j6tg�3 19� ❑ Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE /BBAASSL AMOUNT DUE 4-11.5 AMOUUNNTT REMITTED R{ECCEIVED BY DATEE�7 pPERMIT NO. INFO ! `MOl ✓ EH 13-24 REV. 10/82 } l`� . 1 �� ►3� �� 10/82 500 14-26