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r APPLICATION FOR PERMIT' SAN JOAQUIN,`LOCAL HEALTH,DISTRICT 1601 E. HAZELTON AVE., STOCKTON„CA PERMIT NO.'V,3 • Telephone (209) 466-6781 PERMIT EXPIRES•1 YEAR'FROM DATE ISSUED � �' ' 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 Regulations of the San Joaquin Local Health District: . Job Address .�'d 0 Z ILIA470CIIC [ Subdivision Name Owner's Name _ Address' Z Phone Contractor's Name Qs%.;- -e?�Z '4/�,WLicense No. Phone Q,0,,7,Z. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ OV PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK .�" SEWER LINES. DISPOSAL FLD. PROP. LINE- FOUNDATION INE FOUNDATION _AGRICULTURE WELL, OTHER WELL PITSISUMPS r INTENDED USE TYPE OF WELL= PROBLEM AREA r^- ONSTRUCTIDN SPECIFICATIONS 117 Industrial ❑Open Bottom ❑MantecaDia. of,Well Excavation W ❑ Domestic/Private [:]Gravel Pack t ❑Tracy 'Dia of,Wel l Casing Public ,Other ❑ Delta Type ofCasing � ❑ Irrigation -Approx. Eastern .-.. - Cathodic Protection . Depth Specifications "`�� +�'• °, _bepth of Grout SeaT��,% '-X"" ❑Geophysical e y :r�" lTy;pe of Grout "` . Other Surface Sealstalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 501) ` G i�iu mri.unr•r� � ra iaor. r. TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION �' (No septic tank or seepage�pii perrtiitted if public sewer is s ;;\ava.ilable within 200 feet.) Installation will serve: Residence Commercial _ Other ' fi Number of living units; �- Numbe' of bedrooms 4 Lot size Character of soil to a depth of 3 feetf ! Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Na. Compartments PKG. TREATMENT PLT. Type/Mfg I Capacity .A, *; .` Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation i %,vProperty Line ' DESTRUCTION ❑ LEACHING LINE No. 8 Length of lines _ 1 IvO Total length/size , ..._. ..'YG� FILTER BED ❑ Distance to nearest: Well Foundation Proper y-,0 e,,, SEEPAGE PITS Depth _ Size-.-.3- -.�� -_.- .Number. SUMPS LJ Distance to nearest: Well Foundation /i °""`Property Line F DISPOSAL PONDS , / 'e I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county t ordinances, state laws, and rules and regulations of the San Joaquin Lqcal 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 pei:son-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 applican ust call for all required inspections. Complete drawing on,rewerse side_ ,.K Signed.X7 _�� Title: Date: ,At FO Application Accepted by _7 T USE-ONLY Area SE DNLYArea Q� Stk 466-6781 Additional Comments: AWIle A146!5P_ Lodi -369-3621 . Pit or Grout Inspection b Date x/ 73 Manteca 823-7104 Final Inspection byDate ff �� L Tracy 835-6385 p Applicant - Return all copies to. nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.U. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED'"'`"'"""RECEIVED"BY"""`""`"'"'DATE r" '"� LPERMIT NO; 1 INFO - - --. p yy- [F- -"`33 3-fD3S i _ I EH 13-24 REV. 10/82 10/82 500 1 14-26 1 A