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APPLICATION FOR ?E R.i.. SAN JOAQLi's LOCAL hrALTH 3iSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J y Telephone (209) 466-6781 DATE ISSUED }b 19 93 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Re ulations HV San Joa/ouin ,Loocal Health District. I � J� Job Address HV r !r /1l Subdivision �Name GG X Owner's Name Q E/C Address . /1.1}OO(r ,(f j e a l Phone " 6 4 -- Contractor's Nam Q 1 icense No. F'S 6 7461 Phone Y,31- .5,2 l(f TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR j OTHER J DISTANCE TO NEAREST: SEPTIC TANK /QQ t �"' SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS%SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Oia. of Well Excavation % Domestic/Private Gravel Pack Tracy Dia. of Well Casing 06 11 ❑ Public Other Del to Type of Casing /QVC..: V Irrigation Approx. Eastern Depth Specifications Cathodic Protection t Depth of Grout Seal Geophysical Type of Grout /MJF_ LJ Other Surface Seal Installed b EL7R11.4r Repair Work Done El Type of Pum $ ?B P. State Work Done rt Well Destruction ❑ Well Diameter Sea ing Material (top 50') _ �4- Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION U U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is -.J — available within 200 feet.) + Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg 1, Capacity No. Compartments 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 Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El 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 became 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 ubject to workman's compensation laws of California." The applicant t call I r quired inspe tions. Complete it ing on reverse side. r1 p Signed X Title: �-T� Date: FOR tP T USE ONLY Application Accepted b Area (D9 -„_ KStk 466-6781 Additional Comments: -v [] Lodi 369-3621 Pit or Grout Inspection by Date 1Q-Q8_93 D Manteca 823-7104 Final Inspection by Date //-/T' ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY OATE�ry q PERMIT NO. INFO '4j��2 f�p�� EH 13-24 REV. 10/82 uv^ 1 ` `4�v�500 14-26