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I APPLICATION FOR PERMIT SAN-JOAQU,N LOCAL. HEALTH DISTRICT 1601 E. HAZELTON RUE., STOCKTON, CA PERMIT NO. 3--'60 Telephone (209) 466-6781 DATE ISSUEDZ-�&L_-65_3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) Application is hereby made to the San`Joaquir Local -Health District for a permit to construct and/or install the work herein described. This application is made in compliarce 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. /� A Job Address Subdivision Name O U rGCC 13 Phone Owner's Name Address �/ ,� PQ1 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL C] WELL REPLACEMENT DESTRUCTION W PUMP INSTALLATION €] SYSTEM REPAIR OTHER j S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t/ 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 ! Lj Irrigation Approx. Eastern Depth Specifications P Cathodic Protection N Depth of Grout Seal 17 Geophysical Type of Grout ' {_]Other Surface Seal Installed by Repair Work Done [:] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 50') Depth Filler Material (Below 50') _ ob TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LP+ (No septic tank or seepage pit permitted if public sewer is t 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 E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE Lj No. & Length of lines Total length/size {- FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L—j '` Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i 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 workmang 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 ersons subject to workman's compensation laws of California." The applicant mus r all qui d inspections. Complete drawing on reverse side. Signed X A Title: Date: I R DEPARTME Q Application Accepted by ArStk ea 466-6781 f [� Lodi 369-3621 Additional Com encs: Pit or Grout n e io Date Manteca 823-7104 A Final Inspection by Date ��_��(�_—_ 3 L Tracy 635-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 =� BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. � � � • �o � l c7- t�o �� -Z-�s3 g-3 €� EH 13-24 REV. 10/82 10/82 500 14.-26