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I � APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT -` 1601 E. HAZELTON AVE., STOCKTON-, CA Telephone (209) 466-6731 PERMIT Npl. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 42 y r {Complete in Triplicate} I.f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein and ctheeRuleshanda>kegulationsplication iofmthe Sande cJoaquincLocalwith Health oDistricuin tunty Ordinance No. 549 for sewage or No. 1862ifor well/pump Job Address 3124 Chem ' and Ave. Subdivision Name Owner's NameFc"3K �.ene ,RQnd (Mur h address .3124 Chert land Aye. Phone Contractor's Name N A 931-5099a License No. Phone IM, y, TYPE OF WELL/PUMP WORK: :- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �� I PUMP INSTALLATION ❑ SYSTEM REPAIR (] OTHER DISTANCE TO NEAREST: SEPTIC TANK U SEWER LINES DISPOSAL FL D, PROP. LINE � { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IM } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I !❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing S I] Public Other Delta _V , Lilrrigation Approx. Eastern Type of Casing (] Cathodic Protection Depth Specifications � ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by 1M Repair Work Done ❑ Type of'Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') { Depth Filler Materia) (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is -� Installation will serve: Residence X Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms , Lot size 4O Character of soil to a depth of 3 feet: t Water'table depth _ 551 SEPTIC TANK Type/Mfg concretEA Steel. Capacity 12_9O gal.No. Compartments 2iM PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMt DESTRUCTION ] Distance to nearest: Well Foundation Property Line i I � LEACHING LINE No:: & Length of lines Acle. 10 Total length/size 1001 411 P FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS De Pith 25' Size Numbe « �i r SUMPS [_jDisitance to nearest: Well Foundation Property Line , DISPOSAL PONDS ❑ F 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 wlhich 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 applical must WI for required ' s ection Complete drawing on reverse side. I aQ Signed ( Title: Date: ! i; F D ART NT SE ONLY.- Application Accepted by rea (7 Stk 466-6781 Additional Comments: Lodi 369-3621 f. Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by v Date ❑ Tracy 835-6385 Applicant - Return all copies}to: . Envir m ntal Health Permit/Services 16 1 E. azelton Ave., P.O. Box 2009, Stk., CA� 95201 � FEE BASE AMOUNT DUE AM:::�OUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _ EH 13-24 REV. 10/82 14-26 10/82 500 (1 �J V [L I� II